Behavioral Health Worker Strike Hardship Fund Application

Hardship Fund

Submit this form to request additional funds, if you are having difficulty making ends meet, while on or due to the ULP Strike. Requests will be reviewed by a committee of the Executive Board. We will respond to requests as soon as possible but no later than 2 weeks after the week of the ULP strikes.

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* 1. How Can We Reach You?
Contact info:

First Name:

Last Name:

Email Address:

Cell Phone:

Job Class:

Hourly Rate of Pay:

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* 2. Hospital

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* 3. What is the reason for your hardship request?

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* 4. What is the Request for?

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* 5. What is the amount you are requesting?

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* 6. Have sought any other assistance and if yes, what was it?

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Behavioral Health Worker Strike Hardship Fund Application

Hardship Fund

Question Title

* 1. How Can We Reach You? Contact info:

Question Title

* 2. Hospital

Question Title

* 3. What is the reason for your hardship request?

Question Title

* 4. What is the Request for?

Question Title

* 5. What is the amount you are requesting?

Question Title

* 6. Have sought any other assistance and if yes, what was it?

* 1. How Can We Reach You?
Contact info: