Nominate a Family for Assistance | Tower Family Foundation

Applicant Status(Required)

New Applicant

Previous Donation Recipient

Injured, Afflicted, or Deceased Industry Worker

Full Name(Required)

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

Email Address(Required)

Employer Information

Name of Employer(Required)

Contact Person(Required)

First Last

Phone Number(Required)

Email Address(Required)

Applicant

Is the applicant the same person as the Injured / Afflicted Industry Worker listed above?(Required)

Yes

No

Applicant Full Name(Required)

First Middle Last

Applicant Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Applicant Phone Number(Required)

Applicant Email Address(Required)

Relationship to Industry Worker(Required)

Accident Information

Date of Incident(Required)

Incident resulted in (check all that apply)(Required)

Death

Permanent Disability

Severe Injury

Emergency Room Visit

Hospitalization

Long Term Illness

Other

Location of Incident(Required)

Type of Work Being Performed(Required)

Description of Incident(Required)

Nature of injury suffered, including, if pertinent, likely number of days where Industry Worker will be unable to work:(Required)

NOTE: Applicant may be required to submit additional information if the incident resulted in a severe injury or permanent disability.

If assistance with funeral expenses is requested, name and contact information for Funeral Home:

If there are dependent children who will be eligible for our scholarship program, please list their name(s) and age(s) below:

Donation Recipient Information

Person to Receive Donation (If different from Industry Worker)

Full Name(Required)

First Last

Phone Number(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Relationship to Industry Worker(Required)

Release of Information:

By submitting this application, I, the undersigned, authorize the Tower Family Foundation to share its contents with its Advisory Committee members. Donations of funds by the Foundation to Tower Industry Workers or their Family Members are entirely discretionary. I understand that I am not guaranteed a monetary donation by submitting this application. The signatory represents and affirms that all information submitted in this application is true and correct.

Signature of Industry Worker or Applicant on Industry Worker’s Behalf:

Disclaimer: Personal information collected as part of the application process will become the property of the Tower Family Foundation and will be used by its Advisory Committee for purposes of evaluating applicants. The Advisory Committee has the final decision on determining if the injury fits the definition of “severely injured” or “permanently disabled”. The Committee will evaluate each injury or disability per incident and its decision on each application is final.