Boost Application for Support

Application for Support
Please read the criteria for submission on our website before completing this application. If you (the Nominator) or the teacher in need is not eligible, your application may be dismissed. This application is for financial support in Emergency/Crisis situations relating to medical bills, housing, transportation and food insecurity.
SECTION A: Nominator and Teacher ("Nominee") Details
Nominator Information*

First Name Last Name
Nominator Email
example@example.com
Nominator Role*

Business OwnerMulti- Site Manager
Business Information*

Business NameState License Number
Business Website*
Business Owner Contact
Please enter a valid phone number.
Teacher ("Applicant") in Need*

First NameLast Name
Teacher Email
example@example.com
Teacher Position at Your School & Description of Their Duties*
Teacher Start Date*

MonthDayYear
Date
Teacher Birthdate*

MonthDayYear
Date
Have you ever requested support for this teacher?

YesNo
SECTION B: Teacher Crisis Details

Please provide us with information on your Teacher's needs at this time. By providing us with a detailed explanation of their needs, we will be able to quickly and accurately review and address the application.
B1: Please indicate what type of HEALTH CRISIS your nominee may be experiencing:

Overdue Medical bills for self, spouse, or child (under 18)Medically Necessary Dental WorkPrescription assistanceFood InsecurityOther
Please explain what type of health crisis you are experiencing: You must submit bills that indicate you have overdue or past due bills that require immediate attention. Your application will not be considered unless proof of all bills are submitted.
☝️You must submit bills (see Section B8) that indicate you have overdue or past due bills that require immediate attention. Your application will not be considered unless proof of all bills are submitted.
📃Submission required - In Section B8, documents from your dentist must be submitted showing that the treatment was/is necessary. Future dental work bills may be considered.
📃Submission required - In Section B8, you must submit proof of the cost of the prescription as well as the amount which is covered by the nominee's insurance.
B1.a: Because you've selected Overdue Medical bills, please check all options here that are true.

Insurance will cover some of the nominee's costs.The nominee has applied for charity care through their medical provider.The nominee has discussed a payment plan for their overdue bill(s) with their medical provider.None of the above is true
B1.a.i: What amount has the nominee discussed/agreed upon with their provider?
($USD)
B2: Please indicate what type of HOME CRISIS your nominee may be experiencing:

Eviction Prevention- OVERDUE Mortgage or Rent PaymentsNecessary Home RepairsTransportation related expenses (up to $1,000)OVERDUE Utility PaymentsOther
Please explain what type of home crisis you are experiencing: You must submit evidence in Section 8B.
B2.a Please explain who else lives in the nominee's home and if they contribute to mortgage or rent payments
B2.b Has the nominee applied for utility assistance?

YesNo
B2.b.i Please explain what utility assistance the nominee has applied for
📃Submission required - In Section B8, provide proof of overdue rent/mortgage payments. Documents should indicate the renter’s name, address, amount due and should not be more than 45 days old.
📃Submission required - In Section B8, submit quotes for home repairs requested from certified companies.

Electrical, structural, and water damage, heating and air conditioning or any other necessary repairs that may affect the safety in the home may be considered.
📃Submission required - In Section B8, submit proof of repairs or other documents to show a need for assistance.

Boost caps payments on transportation requests at $1,000.
📃Submission required - In Section B8, provide utility bills indicating the payor’s name, address and amount due.

Proofs should not be more than 45 days old.
B3: Please provide a detailed explanation of your nominee's needs below:*

0/0
B4: Why do you believe the nominee is deserving of financial assistance?*

0/0
B5: Has the nominee applied for or is receiving government benefits?*

YesNo
B5.a: What government benefits has the nominee applied for or is receiving?

Child Care Aware of America (CCAoA)Food Stamps / EBT / SNAP - Supplemental Nutrition Assistance ProgramHouse assistanceMedicaidPIPP - Percentage of Income Payment PlanState-based child care financial assistanceState-based child medical assistanceOther
B5.a.1: What housing assistance program(s) were applied for?
B5.a.2: What state-based child care financial assistance program(s) were applied for?
B5.a.3: What state-based child medical assistance program(s) were applied for?
B5.a.4: You selected "Other." Tell us what government benefit(s) were applied for that weren't listed above
B6: As the business owner, what have you done to support this teacher in need? *
B7: Please indicate a specific monetary request. Proof of Bills is required to substantiate this request before this application can be reviewed. *
USD$
B8: Upload any documents that you believe would support this request for financial assistance. These documents should substantiate the exact amount that is requested above. In the event that these numbers do not match, your application will be delayed and may be dismissed. *

Cancelof
☝️Reminder - You checked "other" health crisis in Section B1, please submit bills that indicate you have overdue or past due bills that require immediate attention.
☝️Reminder - Submit evidence of the "other" home crisis you've detailed in Section B2.
☝️Reminder - Submit documents from your dentist showing that the treatment was/is necessary
☝️Reminder - submit proof of the cost of the prescription as well as the amount which is covered by the nominee's insurance.
☝️Reminder - submit proof of overdue rent/mortgage payments. Documents should indicate the renter’s name, address, amount due and should not be more than 45 days old.
☝️Reminder - submit quotes for home repairs requested from certified companies.

Electrical, structural, and water damage, heating and air conditioning or any other necessary repairs that may affect the safety in the home may be considered.
☝️Reminder - submit proof of repairs or other documents to show a need for assistance.

Boost caps payments on transportation requests at $1,000.
☝️Reminder - provide utility bills indicating the payor’s name, address and amount due.

Proofs should not be more than 45 days old.
B9: If the nominee were to receive funding from BOOST, please provide the best address to which a check can be sent.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SECTION C: Final Steps and Confirmations
How did you hear about BOOST?*
Should be Empty:

Application for Support

SECTION A: Nominator and Teacher ("Nominee") Details

SECTION B: Teacher Crisis Details

📃Submission required - In Section B8, documents from your dentist must be submitted showing that the treatment was/is necessary. Future dental work bills may be considered.

📃Submission required - In Section B8, you must submit proof of the cost of the prescription as well as the amount which is covered by the nominee's insurance.

📃Submission required - In Section B8, provide proof of overdue rent/mortgage payments. Documents should indicate the renter’s name, address, amount due and should not be more than 45 days old.

📃Submission required - In Section B8, submit quotes for home repairs requested from certified companies.

📃Submission required - In Section B8, submit proof of repairs or other documents to show a need for assistance.

📃Submission required - In Section B8, provide utility bills indicating the payor’s name, address and amount due.

☝️Reminder - You checked "other" health crisis in Section B1, please submit bills that indicate you have overdue or past due bills that require immediate attention.

☝️Reminder - Submit evidence of the "other" home crisis you've detailed in Section B2.

☝️Reminder - Submit documents from your dentist showing that the treatment was/is necessary

☝️Reminder - submit proof of the cost of the prescription as well as the amount which is covered by the nominee's insurance.

☝️Reminder - submit proof of overdue rent/mortgage payments. Documents should indicate the renter’s name, address, amount due and should not be more than 45 days old.

☝️Reminder - submit quotes for home repairs requested from certified companies.

☝️Reminder - submit proof of repairs or other documents to show a need for assistance.

☝️Reminder - provide utility bills indicating the payor’s name, address and amount due.

SECTION C: Final Steps and Confirmations