All Applications must have an Advocate to assist in the process and be the point of contact for
the Applicant. Usually the Advocate will be the Chaplain or Human Resources Director.
Please identify with which Signature HealthCARE Facility/Community the Applicant is
If Applicant is a current SHC Stakeholder
Compassion Fund Criteria
Circumstances of Hardship
Please describe the circumstances which you believe demonstrate eligibility for relief assistance.
Please describe fully the TRIGGERING EVENT of your situation, especially as related to the criteria
described on page 3.
Please completely fill in the form below with information on each specific item where you are
requesting assistance. All items should be listed for which help is being requested and a copy of
all corresponding backup for each item should be attached.
Please enclose ALL of the following requested items and check below those that are being
provided as attachments to this application. If there is a compelling reason that a requested item
cannot be provided, please indicate such in the appropriate space.
FAILURE TO PROVIDE THE REQUESTED DOCUMENTATION, EVEN FOR A STATED REASON, MAY
RESULT IN A DELAY OF PROCESSING OR A DENIAL OF AWARD.
REQUIRED ATTACHMENTS‐ (Please indicate below those attached)
Advocates (or other references the Applicant may wish to provide) should provide a brief
explanation of why they believe the Applicant be considered for an award of funds as well as any
other information they consider pertinent to the request.
If the person referring the applicant is someone other than the Advocate, please provide their
names and contact information along with the recommendation.
Feel free to attach testimonies below.
I, the undersigned, have examined this application for assistance and certify the
claim to be valid and that all the answers and information are all true and correct
and that the request for emergency assistance is necessary and the Applicant has
exhausted all other resources available for assistance
The Compassion Fund reserves the right to limit award amounts as
necessary in order to be good stewards of our limited funds so as to be
able to assist as many applicants as possible.
Applicants who are now (or who once were) Signature Stakeholders
must be considered employees in good standing (either now or at the
time when they left) in order to be eligible for assistance from the
Compassion Fund. This requirement also applies to immediate family
members of current or former stakeholders as well.
PLEASE NOTE: All information provided must be current and accurate.
Fraudulent applications will result in denial of your application and may
result in administrative action and/ or legal action as well.