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Home
Healthy Today
Philanthropy
Why Give
Giving Opportunities
Grateful Patient Program
FAQ’s About Giving
Mosaic Life Stories, Cancer Care
CARES Act
Philanthropy Team
Mosaic Life Care Auxiliary
Auxiliary Board of Directors
Auxiliary Funding
Auxiliary Gift Shop
Auxiliary Membership
Volunteer Services
Volunteer Opportunities
Become a Volunteer
Healthy Tomorrow
character education emPowers
emPowerU
e2 Fellowship
Programming Annual Report
STEAM After-School
STEAM Camps
Camp Invention
Healthy Together
character education emPowers
Think Ahead Works®
Scholarships
Grants
Albany
Gift Shop
Hospital Philanthropy
FAQ’s About Giving
Ways To Give
Why Give
Volunteer Services
Become a Volunteer
Volunteer Opportunities
Ways To Give
Donate Now
Application for Financial Assistance
Dr. John Owen Endowment for Caregiver Excellence
PURPOSE
The Dr. John Owen Endowment for Caregiver Excellence was established to provide financial assistance for Mosaic Medical Center - Albany caregivers with first preference given to caregivers who wish to pursue additional education/credentials but are hindered by financial hardships.
CRITERIA
Interested caregivers must submit an application attesting to the following:
a. They are employed in a full or part-time position and regularly scheduled a minimum of 30 (thirty) hours per week at Mosaic Medical Center - Albany.
b. They have a demonstrated financial need that creates a personal hardship for them or their family OR that hinders their ability to pursue additional education or credentials that support their personal and professional goals.
Recipients will be selected by a committee appointed by Mosaic Foundation - Albany Board of Trustees. First preference will be given to caregivers pursuing additional education or credentials that support their personal and professional goals.
REQUIRED APPLICATION INFORMATION
1. Personal Information
2. Narrative Information
DISQUALIFICATION
Please complete the application in its entirety. Incomplete applications may be returned to you, which could delay processing or be denied for consideration.
PERSONAL INFORMATION
Personal information will not be provided to the review committee. Applications are anonymous.
Date
*
MM slash DD slash YYYY
Name
*
First
Last
Caregiver Number:
*
Confirm:
*
I confirm that I am employed a minimum of 30 (thirty) hours per week at Mosaic Medical Center - Albany.
Confirm:
*
I confirm that I have a demonstrated financial need that creates a personal hardship for me or my family OR that hinders my ability to pursue additional education or credentials that support my personal and professional goals.
Department
*
Job Title
*
Home Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
*
Caregiver Email
*
NARRATIVE INFORMATION
The review committee will read these responses. Please do not include personally identifiable information.
Are you renewing a professional license?
*
Yes
No
License title:
*
Describe your desire to pursue additional education or credentials that support your personal and professional goals.
*
Describe the personal financial hardship you are experiencing. Ex: Not having funds to pay for a car repair, unexpected medical bills, etc.
*
Amount requested:
*
How will the amount requested be used?
*
Please upload receipts or bills:
*
Drop files here or
Select files
Max. file size: 500 MB.
Authorization
*
I certify that the facts I have provided in my application are true and complete. I herein authorize Mosaic Life Care Foundation, its affiliates, or a third-party to investigate without liability the information supplied in this application.
Incomplete applications will not be considered by the committee. Falsification of information may result in termination of any financial assistance granted. This application becomes property of the Mosaic Life Care Foundation.
THANK YOU FOR YOUR APPLICATION.