Hurricane & Disaster Relief Application

Hurricane and Natural Disaster Relief Application

The information provided on this form will be used by the WCDDA Fund Committee and WCDDA Officers to determine eligibility. Questions can be addressed with the WCDDA office at 813-654-2500.
Purpose

The purpose of the Hurricane Immediate Relief Program administered through the West Coast District Dental Association Fund is to provide a one-time grant of $500 to render financial assistance to meet dentists' most urgent personal needs immediately following a hurricane.

Immediate Needs: The use of relief grant funds is limited to meeting disaster victims’ most urgent and vital personal needs immediately following a disaster. Emergency grants are not intended for long-term needs such as rebuilding homes and buildings, or replacing household and personal belongings. Grant funds also cannot be used to replace lost income. Emergency Disaster Grant funding is not intended for replacement of dental practice property, dental supplies, staff salary, etc.A disaster is defined as a "sudden occurrence which inflicts widespread catastrophic damage to a large geographic area and/or which generally affects a large number of individuals." as defined in the guidelines below.

Guidelines

Any dentist in West Coast District who is a full-time resident of the state of Florida and is affected by a hurricane may apply to the West Coast District Dental Association Fund for financial assistance.

Applicants are not required to be members of the West Coast District, Florida or American Dental Associations to be eligible to receive a hurricane grant.

Evaluation of Application and Processing Procedures

The grant award for any applicant may be in an amount up to $500. The dollar amount and number of grants made will depend on the number of applicants and the amount of funds available at any given time. The final decision regarding the number, timing and amount of grants is solely within the purview of the WCDDA Fund Committee and WCDDA Officers. Grants for hurricane assistance shall be awarded only once per applicant per disaster.The applicant may obtain an application form from the West Coast District Dental Association office. Application forms must be completed in entirety and notarized.

The application for the hurricane Immediate Relief Program will be reviewed and applicant requesting assistance will be notified within 5 days.
Name*

First NameLast Name
Primary Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Primary Phone Number*

Area CodePhone Number
Nature of Disaster: Provide a description of the disaster. Please be date specific. *
Dental License Number or ADA Number (for verification only) *
Grant Payment Information (Please list physical address where check should be sent. Checks will be sent via USPS.*

Dental Practice AddressHome Address
Amount requested (up to $500)*
I hereby certify the information contained in this document is true and complete.
Signature*

Clear
Should be Empty:

Hurricane and Natural Disaster Relief Application