Safety Fund Application 2026

Survivor Safety Fund Application 2026
The Survivor Safety Fund provides non-interest-bearing micro-loans and nonrepayable grants to women, Two-Spirit, Transgender, and gender-diverse individuals who are currently fleeing gender-based violence, OR who have fled within the last four weeks and have not stayed within formal emergency accommodations during that period. Funds can be used to access basic needs and safety.

To qualify for the Safety Fund, you must meet the following eligibility criteria:
- Be currently fleeing gender-based violence OR you have fled gender-based violence within the last 4 weeks
- You have NOT stayed in formal emergency accommodations since fleeing gender-based violence (e.g., shelter, second-stage housing)
- Currently reside in Nova Scotia, have fled Nova Scotia within the last 12 months, or will be using program funds to return to Nova Scotia
- Must be 18 years of age or older at time of application.
- Must have your own bank account, or be willing to open one during the application process.
Please note that applications are considered on a case-by-case basis, depending upon the availability of funding and presenting needs. Submitting an application does not guarantee that you are approved for funding or case management.

Due to a high volume of applications, it can take 5-7 business days for the December 6th Team to respond to your request. We appreciate your patience.
Referral Source*
Legal Name*

First NameLast Name
Alias/ Preferred Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
She/herHe/himThey/themOther
I am still living in a home that is affected by gender-based violenceI have already fled gender-based violence
Live aloneWith roommatesWith partnerWith family or friendsRemaining in the homeShelter or transition house2nd stage housingHomelessN/A, I have not left yetOther
When was your most recent experience of gender-based violence?*
The Survivor Safety Fund is meant to help survivors relocate from a space that is affected by gender-based violence. Can you describe how this fund would help you access safe housing if you have recently fled an unsafe home or if you are currently living there?*
Phone callTextEmailIn-person meetings
Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Email Address*
Safety concerns can take many forms. This may include physical or sexualized violence, threats of violence, unwanted contact (harassment, monitoring, stalking), manipulation, humiliation, control or domination, and financial control. This is not an exhaustive list and the December 6th Team encourages you to choose the option that feels best to you, even if your specific concerns are not reflected in these examples.
Yes, I have safety concerns related to my experience of gender-based violenceNo, I do not have any concerns about my safety
With as little or as much information as you feel comfortable providing, please briefly describe your current safety concerns. *
MaleFemaleTransNon-BinaryTwo-SpiritOther
WhiteBlackIndigenousArabicAsianEast IndianAfricanLatinoPrefer not to sayOther
Canadian BornCanadian NaturalizedPermanent ResidentRefugeeOther
Home Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Own carTaxiBusWalkingOther
Employed full-timeEmployed part-timeSelf-employedSeasonally employedUnderemployedUnemployed by choiceUnemployed b/c of disabilityUnemployedStudent
EmploymentESIACPP (OAS or disability)EIChild supportChild tax benefitHousing subsidyPartner's incomeNo incomeOther
Married or common-lawRelationship (not living together)Divorced, separated, or widowedSingleOther
YesNo
Yes, live with meYes, don't live with meYes, in temporary careYes, in permanent careChildren are adult(s)No children
YesNoI do not have children
Please provide an emergency contact*

First NameLast Name
Relationship to you*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
HousingFood supportEducationParenting supportExiting traffickingChildcareHealthcareLegal/court supportsService navigationGender-affirming healthcareSubstance use supports (harm reduction or recovery)Mental health supportsSafety planningEmployment supportsOther
Your confidentiality is important to us. If you require additional services within, or beyond the scope of the December 6th Program and would like YWCA Halifax to contact other programs and services on your behalf, please sign this consent form. We will consult with you on what information can and cannot be shared before communication of personal information to any service provider. You may revoke consent at any time. Disclosure of data and personal information will be limited to individual consent gained or in the case of subpoena or legally required disclosure such as the Duty to Report.
I, (print your name)*
Name
Other YWCA staff/programsMy landlordUtility companyChild/ family servicesIncome assistanceLawyers/ legal aidParole/probation officerOther non-for-profit agencyOther
Please provide the contact information (Program Name/Contact Person Name, Email Address & Phone Number) for options check-marked above.
YWCA Halifax will be entering your data into a secure database and may use anonymous and de-personalized data collected on this form for the purposes of research. program planning, policy development and/or organizational strategic planning. This means you will not be identifiable and your comments will be kept confidential. This information is sometimes required by funders to evaluate the effectiveness of the program, and will assist us in serving you, and all of our participants better. YWCA Halifax will collect and store electronic data on for the purposes of:

a. Case management
b. Program coordination and development
c. Statistical reporting
d. Research
e. Program evaluations
f. Funder compliance
g. Fund development
h. Partnership development
i. Payroll
j. Emergency contact
k. Human resources

No data or personal information will be collected or stored which falls outside any of these stated purposes. YWCA Halifax will limitthe use of data and personal information to the purposes stated above. YWCA Halifax will retain data and personal information for no longer than 7 years.
Signature*
Witness signature (if under 18 years old)
Should be Empty:

Survivor Safety Fund Application 2026