Springbrook HELP Committee Fund Application

Springbrook HELP Committee Fund Application
The Springbrook Foundation designates a portion of Annual Fund contributions to the HELP Committee, which is comprised of volunteer staff members from across Springbrook and its affiliates.

Each year, the HELP Committee considers requests for financial assistance from people who receive services from Springbrook Partners and affiliates, and have a specific need that is not met through personal or other available resources.

Application considerations include: meeting safety needs, activities not covered by other funding sources (e.g., memberships, lessons, etc.), equipment purchases (e.g., bicycle, electronic learning equipment, etc.) and Holiday Gifts ($125 maximum). Please note that dependent upon budget allocations and the volume of applicants received, there is no guarantee of application approval or approval of the full amount requested.

Please note:
- The application submission deadline for Christmas funds/gifts is the second Friday of November.
- Gift cards are not an option.
- If previous awards were granted for which receipts were not returned, any new applications may not be approved.
- Applications will not be considered if there is lack of documentation to show that other resources/supports denied financial assistance.
If you have any questions regarding funds, distribution, or eligibility, please contact:
- Helpcommittee@springbrookny.org
- 607.286.7171, ext 271
Application Date:*

MonthDayYear
Date
Name of person you are requesting funds for (if self, type your first and last name): *

First NameLast Name
Person's age:*
Person's primary Springbrook affiliate program:
Name of person completing the form*

First NameLast Name
If you are a care manager or a Springbrook employee, please indicate your job title (i.e., CCM, Residential Manager)
Your email Address:*
example@example.com
Your phone number:*

Area CodePhone Number
Extension if applicable
Extension
Your affliation to the person for whom the HELP Committee funds are being requested:

AdvocateCare ManagerFamily MemberGuardianSelfSpringbrook Employee
Please provide the justification for this request to the HELP Committee.*
Describe other attempts made to meet the person’s/your needs (i.e., DSS, Family Resource Network, Catholic Charities):*
Date of request

MonthDayYear
Date
Please share a screenshot/download of the denial or rejection from other organizations to obtain the funds (i.e., Insurance, Family Resource Network, Department of Social Services, Catholic Charities). You can also share the policy that verifies why another agency will not approve the requested funds or items.

Browse Files

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Is this a request for a direct order from Amazon or to receive a check?*

AmazonCheck
Amount of HELP Committee funds requested: *
Purpose of Funds
Other Purpose of Funds*
Was this cost/item previously covered by another organization in the past ? If so, please share the year and which organization. If not, write N/A.*
Is this a cost that was previously covered by FSS?*

YesNo
Please attach a screenshot or download of the cost/bill/invoice/estimate. This will assist the committee in making their decision for approval.

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Cancelof
* Please avoid having the check made directly to the person receiving services because it is reportable and may impact their benefits for that month.
If the request is granted, who should the HELP Committee make the check payable to?*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please Note:

The information above is accurate to the best of my knowledge. I understand that receipts are required to be emailed to the HELP Committee (Helpcommittee@springbrookny.org) within 2 months of purchase. I understand that failure to submit receipts may impact future consideration of my applications.

If you have any questions regarding funds, distribution, or eligibility, please contact:
- Helpcommittee@springbrookny.org
- 607.286.7171, ext 271
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