Wingstop Charities Team Member Foundation Assistance Interest Form

To apply for a grant from the Wingstop Charities Team Member Foundation, please complete the application below. The application will be reviewed by the Team Member Foundation assistance committee.

Eligibility Requirements

This application is only for Wingstop team members.

Team members must be actively employed for a minimum of six months by WRI or by a United States Brand Partner in good standing. The date of the situation must be within the past 60 days from date of application. Supporting documentation is required to be submitted as part of the application.

Examples of qualifying situations include:

Natural disaster (such as tornado, hurricane, flood, etc.)
Qualified disaster (a presidentially-declared disaster/FEMA)
Personal hardship (such as fire, serious illness or injury)

The following unforeseen/unavoidable situations may be eligible for assistance:

An injury or sustained illness that prevents a team member from working for a period of two weeks or more and that results in extraordinary medical expenses.
An injury or sustained illness of a team member’s spouse or child resulting in extraordinary medical expenses.
A fire or natural disaster resulting in damage to or destruction of a home or apartment occupied by the team member.
The death of a team member or of a team member’s spouse or child.

Section 1: Applicant Information

*Applicant first name:

*Applicant last name:

*Email:

* Phone number:

*Permanent address:

*City:

*State:

*ZIP:

*Country:

Current mailing address (if different from above):

Mailing address:

City:

State:

ZIP:

Country:

Where are you employed?

*Employee Type:

*Job title / Position:

Length of time employed: *Months: *Years:

* Restaurant Number:

* Company Name:

Section 2: Hardship Details

* Which emergency situation has caused you financial hardship?: Natural disaster (such as tornado, hurricane, flood or the like)
Qualified disaster (a Presidentially-declared disaster)
Personal hardship (such as fire, serious illness or injury)

*Type of situation: (Example: hurricane, tornado, fire, flood, injury, illness)

*Date of situation: (Must be within past 60 days)

*Please explain the emergency causing financial hardship:

*Number of family members affected:

*Relationship of affected members:

*Describe your immediate needs:

*Amount Requested:

Eligible team members may receive no more than $5,000 within a 12-month period. Funds will be paid directly to the providers.

Section 3: Natural Disaster Information

If the emergency situation was a natural disaster, please complete the following. If not, please continue to Section 4.

If request is for home damage:

1. Is home owned or rented?: Owned Rented

2. Do you currently reside in the damaged home?: Yes No

3. Will you be able to return to this home?: Yes No

If request is for car damage:

1. Estimated value of car:

2. Is car repairable or total loss?: Repairable Total loss

If your home or automobile was damaged, will insurance cover part of the cost?: Yes No

How much?:

Your deductible amount:

Have you applied for any other relief funds or have any other relief funds been provided to you? (If yes, describe; for example: FEMA, Red Cross, disaster grants, Social Security or government grants, etc.):

Please provide your best estimate of the replacement value for the items damaged:

Section 4: Supporting Documentation

Documents may include bills incurred as a result of the qualifying event, supporting photos or receipts.

Supporting Documentation

Cannot add more than 25MB of files.

No more files may be added.

At least one file is required.

That file type is not allowed.

Section 5: Certification and Agreement

I hereby certify that the information provided in and with this Application is true and accurate. I am aware that any statements made herein which are willfully false are subject to penalty under applicable state and federal laws. Submission of this Application does not entitle me to any claim against Wingstop Charities or its Team Member Assistance Fund, but constitutes an application for assistance.

I also understand that by signing below, I hereby authorize representatives of Wingstop Charities to obtain necessary information to assist Wingstop Charities with the review of this Application, including information regarding my salary, benefits, employment status, insurance coverage and other information relevant to this Application. I hereby waive any privacy rights granted to me under the Health Insurance Portability and Accountability Act of 1996 relative to the release of otherwise protected information regarding my health that may be relevant to this Application.

I am making this Certification and Agreement voluntarily and my consent to information exchange and waiver of privacy rights will expire automatically on the first to occur of the disclosure of the requested information or one hundred eighty (180) days after the date hereof.

I have read this Certification and Agreement and understand that there may be significant consequences for providing false information on this Application.

I agree>