H.E.A.L. Member Registration Form

H.E.A.L. Membership Application

Complete Sections I through III of the application. Section IV and V is optional.

1. Provide email address and phone number. Sign and date page 3.
2. Provide proof of household income for all adults listed on the application.
3. Attach copy of Current Fiscal Tax Return/Form1040, pages 1&2 only. DO NOT send W-2 forms.
4. If your current household income has changed significantly from your 2018 tax return, provide proof of household income such as YTD pay stubs w/explanation.
5. Attach documentation for all amounts listed below in Section III “Annual Household Income”. Provide proof of dependency. All supporting documentation must be provided with the application or it will be returned and not processed.
6. Return this application and copies of all required documents to the address, email, or fax noted on the bottom of page 2.
7. Assistance expires annually from the date approved. Applications that are incomplete or do not have correct/sufficient documentation will be returned, unprocessed.

Are you authorized to work in the United States?

Are you a citizen of the United States?

Have you ever worked for this company?

Have you ever been convicted of a felony?

For each additional Family member add:

IV. If your income level is above the limits stated in the chart above, but the regular price is beyond your ability to pay due to extenuating circumstances, please explain below. An example of special circumstances may include medical expenses. In such a case you may be required to provide proof of medical bills paid out of pocket for the amount you are over the limit to qualify. This would not include medical insurance premiums for the current year.

NOTE: Financial Assistance will not apply to Programs or Childcare until the application is approved. Assistance cannot be applied retroactively. Applications can take up to two weeks to process, or longer if the application is incomplete. You will be notified by email or mail regarding the status of your application.

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I hereby certify, under penalty of perjury, that the information that I have provided is true and correct as of this date to the best of my/our knowledge. I authorize H.E.A.L and their assigns to have access to all financial records necessary to verify the information contained in this application. I agree to notify H.E.A.L within 10 working days of any changes of circumstances regarding information contained in this application; otherwise, this Financial Assistance is valid through April 30, 2020. I agree to respect and follow all H.E.A.L policies and procedures.