Sport Clips Eric Gozur - Wayne McGlone Memorial Relief Fund (SCEGWMMRF)

Eligibility Parameters

Do not submit partial applications - wait until you have all documentation and submit everything together.

Eligibility Criteria

- Employees who have worked for Sport Clips, Inc. or a Franchisee of Sport Clips, Inc. for three or more consecutive months; an exception to the three month minimum rule may be made by a unanimous vote of the Independent Review Committee.
- Full-time or part-time employees are eligible regardless of whether hourly or salaried or position held.
- Surviving dependents or family members of a deceased, eligible employee who was employed by Sport Clips at the time of death.

Disqualifying Events - these are not eligible for a relief payment
- Moving costs.
- Expenses related to divorce.
- Repairs and/or general maintenance of vehicles.
- Maternity leave, unless there is some medical issue involving the mother or baby.

Qualifying Events and Maximum Relief Payments

Independent Review Committee members have the discretion to award relief payments up to the maximums listed below. Relief payments are primarily based on out-of-pocket, documented (by an outside party - such as a receipt) expenses, and depending on the circumstances, a relief payment may be less than the requested amount. The amount of each relief payment will be evaluated based on individual need, financial ability to cope with the event (which would take into consideration insurance coverage for the event), and the Fund balance.

- Death of an employee or immediate family member: $15,000 ($5,000 limit for the death of a parent)
- Serious injury or illness of any employee or family member within the same household: $10,000
- Loss of or severe damage to housing resulting in financial hardship: $10,000
- Loss of or severe damage to automobile resulting in financial hardship: $ 5,000
- Other unexpected catastrophic events: $10,000

Total relief payments to any one employee and/or their family within the same household may not exceed $25,000 in any twelve month period.

Documentation

Please select one of the following statements:*

I have requested relief funds from SCEGWMMRF in the past for this situation. I have requested relief funds from SCEGWMMRF in the past for a different situation unrelated to the current issue. I have requested relief funds from SCEGWMMRF in the past, but did not receive any relief funds. I have never applied to the SCEGWMMRF for relief funds.

Check all boxes related to your situation for which you are seeking a relief payment.*

Medical Issue Lost Wages Vehicle Damage Housing Damage Death of a Loved One Natural Disaster

There is a lawsuit and/or legal action regarding my situation and/or circumstances.*

Yes No

Other:

For the lawsuit and/or legal action, please give a brief update on the status of it.*

Have you received any assistance from crowdfunding (ie. Go Fund Me), your Team Leader or another source regarding your situation and/or circumstances?*

Yes No

Briefly describe the crowdfunding or other assistance that you have received.*

Upload a list of everything for which you are seeking a relief payment, including the total amount.*

No File Chosen

File uploads may not work on some mobile devices.

Medical Issue Documentation

I have medical insurance.*

Yes No

Briefly describe the situation for which you are seeking a relief payment.*

Upload a note from your doctor that includes BOTH your diagnosis and estimated time off of work.*

No File Chosen

File uploads may not work on some mobile devices.

Upload your FINAL medical bill(s) that reflect any adjustments by insurance or the Provider. DO NOT SUBMIT "Explanations of Benefit", only final medical bills.*

No File Chosen

File uploads may not work on some mobile devices.

Up to 5 documents can be uploaded, if you have more than that, please consolidate the pages into fewer files to be uploaded together.

I have additional documents to upload.*

Yes No

Upload your FINAL medical bill(s) that reflect any adjustments by insurance or the Provider. DO NOT SUBMIT "Explanations of Benefit", only final medical bills.

No File Chosen

File uploads may not work on some mobile devices.

Up to 5 documents can be uploaded. If you have more than that, please consolidate the pages into fewer files to be uploaded together.

Upload your FINAL medical bill(s) that reflect any adjustments by insurance or the Provider. DO NOT SUBMIT "Explanations of Benefit", only final medical bills.

No File Chosen

File uploads may not work on some mobile devices.

Up to 5 documents can be uploaded. If you have more than that, please consolidate the pages into fewer files to be uploaded together.

Upload your FINAL medical bill(s) that reflect any adjustments by insurance or the Provider. DO NOT SUBMIT "Explanations of Benefit", only final medical bills.

No File Chosen

File uploads may not work on some mobile devices.

Up to 5 documents can be uploaded. If you have more than that, please consolidate the pages into fewer files to be uploaded together.

Upload your FINAL medical bill(s) that reflect any adjustments by insurance or the Provider. DO NOT SUBMIT "Explanations of Benefit", only final medical bills.

No File Chosen

File uploads may not work on some mobile devices.

Up to 5 documents can be uploaded. If you have more than that, please consolidate the pages into fewer files to be uploaded together.

Lost Wages

Please note that lost wages incurred from a company other than Sport Clips, Inc. for a spouse or family member living in the same household are not eligible for a relief payment.

Briefly describe the impact the situation is having on your wages and/or tips.*

Upload a copy of a recent paystub from Sport Clips, Inc.*

No File Chosen

File uploads may not work on some mobile devices.

Vehicle Damage

Please note that the following are not eligible for a relief payment:
- General maintenance and/or repairs for a vehicle.
- Auto accidents involved in a lawsuit or legal action of any kind.

Briefly describe the situation for which you are seeking a relief payment.*

I have auto insurance.*

Yes No

Upload the final insurance report showing BOTH the deductible you paid and any payout to you.*

No File Chosen

File uploads may not work on some mobile devices.

Upload a copy of the police report from the incident.*

No File Chosen

File uploads may not work on some mobile devices.

Housing Damage

Briefly describe the situation for which you are seeking a relief payment.*

Select if you are the Renter or Owner of your home.*

Renter Owner

I have renter's insurance.*

Yes No

I have homeowner's insurance.*

Yes No

Upload a copy of the final report from your insurance company showing BOTH the deductible you paid as well as any payout made to you.*

No File Chosen

File uploads may not work on some mobile devices.

Upload a copy of the police and/or fire department report from the incident.*

No File Chosen

File uploads may not work on some mobile devices.

Death of a Loved One

Was it the Team Member OR the Family of a Team Member that passed away?*

Team Member Family of a Team Member

Household information*

At the time of their death, the Family Member lived in the SAME household as the Applicant/Team Member At the time of their death, the Family Member lived in a DIFFERENT household than the Applicant/Team Member

Contact Person's Name for the deceased Team Member*

First Name

Last Name

Contact Person's Email for the deceased Team Member*

Contact Person's Phone for the deceased Team Member*

Contact Person's Address on behalf of the deceased Team Member*

Address Line 1

Address Line 2

City

State

ZIP Code

Briefly describe the relationship of the Team Member to the deceased loved one.*

Is there a life insurance policy for the deceased?*

Yes No

Upload a copy of the final report from the insurance company showing any payout made on behalf of the deceased.*

No File Chosen

File uploads may not work on some mobile devices.

Upload a copy of the death certificate.*

No File Chosen

File uploads may not work on some mobile devices.

Upload a copy of the funeral invoice(s). Please note, celebration of life expenses are not eligible for a relief payment.*

No File Chosen

File uploads may not work on some mobile devices.

Up to 5 documents can be uploaded. If you have more than that, please consolidate the pages into fewer files to be uploaded together.

Upload a copy of the receipt of payment for all funeral costs, including who paid for each portion.*

No File Chosen

File uploads may not work on some mobile devices.

I have additional documentation to upload.*

Yes No

Please upload additional documentation here.

No File Chosen

File uploads may not work on some mobile devices.

Please upload additional documentation here.

No File Chosen

File uploads may not work on some mobile devices.

Natural Disaster

Briefly describe the situation for which you are seeking a relief payment.*

I have applied for FEMA (Federal Emergency Management Agency) assistance.*

Yes No

Upload the decision from FEMA - either approval or denial - along with any amount that you received.*

No File Chosen

File uploads may not work on some mobile devices.

I have applied for Red Cross or other national relief organization assistance.*

Yes No

Upload the notification with the amount you received from the Red Cross or other national relief organization.*

No File Chosen

File uploads may not work on some mobile devices.

If you have received other assistance (i.e. your Team Leader, Go Fund Me, local churches or organizations), please upload the notification/documentation here.

No File Chosen

File uploads may not work on some mobile devices.

Applicant/Team Member Contact Information

Check one of the following*

I am the Applicant/Team Member at Sport Clips, Inc. I am the Contact Person filling out the application on behalf of the Applicant/Team Member - please follow up with Applicant/Team Member regarding any questions. I am the Contact Person for the Applicant/Team Member - the Applicant/Team Member is deceased.

Applicant/Team Member Name*

First Name

Last Name

Mailing Address - This cannot be a P.O. Box, it must be a physical address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email Address*

Phone Number *

Date Continuous Employment Began*

Date of Loss Event*

Amount Requested* $

Team Leader/Owner Information

Primary Store Number *

This is usually the State and a number, (i.e. TX123), if you do not work at any specific store, please explain your role.

Name of Team Leader/Owner for your Store*

This is NOT your manager, this is the Team Leader/Owner of the store. If you do NOT work for a specific Team Leader, please explain to whom you report.

Staff Review of Submitted Application - request TL Letter and CONTINUE PROCESS or DENY

Name of Staff that is reviewing this application.*

First Name

Last Name

Request TL info or Deny application?*

Request the Team Leader (TL) information for this application.. This application is DENIED due to ineligibility.

Email Address of the Team Leader/Owner*

Staff - Reason for DENIAL - the reason will be emailed to Applicant.*

While the situation certainly indicates a hardship for the Team Member, it is outside the scope of this Relief Fund. The Team Member did not meet the 3-month minimum work requirement prior to the situation occurring. The Applicant has a lawsuit and/or legal action pending regarding this situation. The Applicant has already received compensation through another responsible party.

Other:

Documentation submitted by Team Leader/Owner

What was Applicant/Team Member's initial start date?*

What is Applicant/Team Member's employment status?*

Active Inactive

Other:

Is Applicant/Team Member employed part-time or full time?*

Part-time Full time

Provide details of their lost wages such as total hours missed, average hourly rate (base pay plus tips), etc., and briefly describe any support the applicant has already received (sick leave, vacation time, paid time off, other).*

What is the estimated total of any lost wages and tips that the Applicant/Team Member has incurred?* $

Please list gross, not net amount.

Write a brief letter of recommendation for this Applicant/Team Member OR if you do NOT support relief funds for this application, please briefly explain why not. *

Without a letter of recommendation, the application WILL BE DENIED.

Staff Review of TL information and either CONTINUE PROCESS or DENY

Name of Staff that is reviewing this TL information.*

First Name

Last Name

Continue process or deny?*

Team Leader information is in order, this application should go to the committee for consideration. This application is DENIED due to ineligibility.

Staff or Team Leader - Reason for DENIAL - the reason will be emailed to Applicant.*

While the situation certainly indicates a hardship for the Team Member, it is outside the scope of this Relief Fund. The Team Member did not meet the 3-month minimum work requirement prior to the situation occurring. The Applicant has a lawsuit and/or legal action pending regarding this situation. The Applicant has already received compensation through another responsible party.

Other:

Which Review Committee will consider this application?*

East - Molly, Arif and Laura West - Tom, Debra and Maria

Review Committee Member #1*

Review Committee Member #2*

Review Committee Member #3*

Committee Member #1 Consideration - application is ready for review

Committee Member #1 - type your name*

First Name

Last Name

Committee Member #1 - Vote *

I APPROVE this application for the amount listed below. I DENY this applicant any relief payment.

Committee Member #1 - briefly give your the reasoning for your APPROVAL vote. *

Committee Member #1 - Reason for DENIAL - the reason will be emailed to Applicant.*

While the situation certainly indicates a hardship for the Team Member, it is outside the scope of this Relief Fund. The Team Member did not meet the 3-month minimum work requirement prior to the situation occurring. The Applicant has a lawsuit and/or legal action pending regarding this situation. The Applicant has already received compensation through another responsible party.

Other:

Amount that Committee Member #1 recommends the recipient to receive.* $

Committee Member #2 Consideration - application is ready for review

Committee Member #2 - type your name*

First Name

Last Name

Committee Member #2 -Vote*

I APPROVE this application for the amount listed below. I DENY this applicant any relief payment.

Committee Member #2 - briefly give your the reasoning for your APPROVAL vote. *

Committee Member #2- Reason for DENIAL - the reason will be emailed to Applicant. *

While the situation certainly indicates a hardship for the Team Member, it is outside the scope of this Relief Fund. The Team Member did not meet the 3-month minimum work requirement prior to the situation occurring. The Applicant has a lawsuit and/or legal action pending regarding this situation. The Applicant has already received compensation through an(other) responsible party(ies).

Other:

Amount that Committee Member #2 recommends the recipient to receive. * $

Committee Member #3 Consideration - application is ready for review

Committee Member #3 - type your name*

First Name

Last Name

Committee Member #3 -Vote*

I APPROVE this application for the amount listed below. I DENY this applicant any relief payment.

Committee Member #3 - briefly give your the reasoning for your APPROVAL vote. *

Committee Member #3- Reason for DENIAL - the reason will be emailed to Applicant. *

While the situation certainly indicates a hardship for the Team Member, it is outside the scope of this Relief Fund. The Team Member did not meet the 3-month minimum work requirement prior to the situation occurring. The Applicant has a lawsuit and/or legal action pending regarding this situation. The Applicant has already received compensation through an(other) responsible party(ies).

Other:

Amount that Committee Member #3 recommends the recipient to receive.* $

Staff confirmation of Majority Vote

Name of Staff that is confirming the majority vote.*

First Name

Last Name

Is the majority of the committee in agreement on the vote?*

Yes No

INSTRUCTIONS FOR THE "STATUS" BELOW:

HOLD - If there is not consensus, CTXCF Staff must email (from sportclipsrelief@ctxcf.org) the members of the appropriate committee (all of them or only the one that doesn't seem to reflect the submitted documentation) with a brief explanation of the discrepancy. Copy and paste the data or get a copy of the application form as a PDF from Formstack that will have ALL the data for a particular application. DO NOT ENTER ANYTHING INTO "STATUS" BELOW UNTIL A MAJORITY VOTE IS ACHIEVED, THE APPLICATION WILL BE ON HOLD UNTIL "STATUS" HAS A SELECTION AND THE SUBMIT BUTTON HAS BEEN CLICKED.

APPROVED - If there is consensus for the vote among all committee members AND there is consensus about an amount to be awarded, complete this section of the Form and click "Submit".

DENIED - If there is consensus to deny a relief payment to an applicant OR CTXCF Staff has determined the application is ineligible, continue to the next step in the process by completing this section of the Form.

Status of application - Approve or Deny*

APPROVED - Review Committee agrees to distribute funds for this applicant in the amount listed below. DENIED - Per Review Committee - NO funds will be issued for this applicant. DENIED - Per CTXCF Staff, the application is DENIED and/or ineligible for further consideration.

Do NOT select one of these if there is not a majority vote.

Should the check be made out to the Applicant/Team Member or to another Payee designated by the Contact Person working on behalf of the Team Member?*

Applicant/Team Member Payee other than the Applicant/Team Member - review the application data to find the Contact Person

A check should be issued for this amount:* $

Reason for DENIAL - the reason will be emailed to Applicant*

While the situation certainly indicates a hardship for the Team Member, it is outside the scope of this Relief Fund. The Team Member did not meet the 3-month minimum work requirement prior to the situation. The Applicant has a lawsuit and/or legal action pending regarding this situation. The Applicant has already received compensation through an(other) responsible party(ies).

Other:

Eligibility Parameters

Do not submit partial applications - wait until you have all documentation and submit everything together.

Eligibility Criteria

Disqualifying Events - these are not eligible for a relief payment - Moving costs. - Expenses related to divorce. - Repairs and/or general maintenance of vehicles. - Maternity leave, unless there is some medical issue involving the mother or baby.

Qualifying Events and Maximum Relief Payments

Documentation

Medical Issue Documentation

Lost Wages

Vehicle Damage

Housing Damage

Death of a Loved One

Natural Disaster

Applicant/Team Member Contact Information

Team Leader/Owner Information

Staff Review of Submitted Application - request TL Letter and CONTINUE PROCESS or DENY

Documentation submitted by Team Leader/Owner

Staff Review of TL information and either CONTINUE PROCESS or DENY

Committee Member #1 Consideration - application is ready for review

Committee Member #2 Consideration - application is ready for review

Committee Member #3 Consideration - application is ready for review

Staff confirmation of Majority Vote

Disqualifying Events - these are not eligible for a relief payment
- Moving costs.
- Expenses related to divorce.
- Repairs and/or general maintenance of vehicles.
- Maternity leave, unless there is some medical issue involving the mother or baby.