BC Hospitality Foundation · Application for Assistance

Date of application

(mm/dd/yyyy)

PERSONAL INFORMATION

Phone

*

Name

*

First Name

Last Name

Birth Date

*

Age

*

Sex

*

M

F

Relationship

*

Single

Married

Divorced

Separated

Widowed

*

Mr.

Mrs.

Miss

Ms.

Email

*

Verify Email

*

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Name of Spouse/Partner

Ages of dependent children

Current Employer

Employer contact name, title and telephone

Please attach your resume

If you don't have resume, please provide working history

MEDICAL INFORMATION

We may ask for more detailed information and/or medical records at a later date.

Family Doctor Name

Family Doctor telephone

Family Doctor Address

Nature of Medical Condition

Provide supporting medical documents

File Upload

Is this medical condition related to:

ICBC claim

Workplace incident:

If yes, have you sought legal advice:

yes

no

Additional information

Please check all that apply

Have you applied for Medical EI

Have you applied for disability insurance

Have you applied for a short term loan

Do you have an ongoing GoFundMe page or other fundraising activities

FINANCIAL INFORMATION

We may ask for more detailed information and/or records at a later date.

Total FAMILY NET income (monthly) - list all sources

Total FAMILY NET income (monthly) $$$

Savings

Assets (RRSP, vehicle, property, etc.)

Other

Total FAMILY expenses (monthly) - list all

Utilities, food, medical costs, transportation, daycare, other....

Total FAMILY expenses (monthly) $$$

Housing

Mortgage

Rent

ASSISTANCE REQUESTED

Support being requested

In a few words, "what would you need the BC Hospitality Foundation to provide to you.

Cost of equipment $$$ (if applicable)

Amount $$$ requested

Additional notes

Are you currently receiving:

Short term disability

Long term disability

Summarize how assistance from the BCHF will benefit you

Include details of WHY and WHAT support you need