EMPLOYEE EMERGENCY FUND APPLICATION

Click here to upgrade your Flash Player.

Ambassadors of Service - Employee Emergency Fund Online Form

Valley Baptist Medical Center

Harlingen

Brownsville


Name		Date		Date of Hire


Mailing Address		Employee # or SSN


DOB:		Department:		Job Title

Sex

Marital Status


Phone Numbers (at least 2)

* A check in the boxes below will verify that you have read and agreed to the terms outlined.

I understand that the employee assistance professional is acting in the role of Employee Emergency Fund (EEF) interviewer, and must share information relevant to making an EEF determination with the EEF committee.

I understand that this fund has been established to assist VBHS employees and their families with EMERGENCY needs, related to necessities of daily living issues.

As a potential recipient of this EEF, I agree to keep confidential all information pertaining to the amount of assistance to be received and the purpose for which this assistance is to be used.

I certify that everything I have told the interviewer is true and complete.

I understand that the staff of the Employee Emergency Assistance Program will attempt to reach me about my EEF determination. This process may take from up to 7 working days and may be by phone or in writing, if they are unable to reach me by phone).

I give the Employee Assistance Staff permission to call me, and/or leave a message with the following people, at the following numbers (give at least 2 contact numbers).


Name		Phone Number

Name		Phone Number

PLEASE MAKE SURE TO BRING YOUR LAST TWO (2) PAYCHECKS AND YOUR PAST DUE BILLS, WHEN GOING TO YOUR INITIAL APPOINTMENT WITH THE EMPLOYEE ASSISTANCE PROGRAM.

* The Employee Emergency Fund is generously supported through the fundraising efforts of the VBHS Ambassadors of Service, and through a perpetual endowment fund supported by the VBMC-Harlingen Auxiliary.