Skip to content
MyChart Login
Scheduling
Billing & Insurance
Contact
Toggle Navigation
Find Locations
Find Providers
Medical Services
Contact
Scheduling
Pay a Bill
MyChart Login
Search for:
Search for:
Find Providers
Medical Services
Find Locations
Search for:
Home
|
Staff / Employees
|
Benefits and Wellness
|
Employee CareFund Program Application
Employee CareFund Program Application
Name
(Required)
Date
(Required)
Employee ID/Badge #
(Required)
Address
(Required)
City
(Required)
State
(Required)
Zip Code
(Required)
Department
(Required)
Current Position
(Required)
Hire Date
(Required)
Job Status
(Required)
FT
PT
PRN (worked minimum hours of 250 over the last nine (9) months)
Email
(Required)
Phone Number
(Required)
Reason for Employee CareFund Need
(Required)
File
Max. file size: 50 MB.
Please upload invoices, statements, bills, etc.
Consent
(Required)
I have read and understand the policy for the Employee CareFund Program and certify I meet all eligibility requirements.
Consent
(Required)
I certify I have completed nine (9) consecutive months of service with Cheyenne Regional.
Consent
(Required)
I certify I have had no corrective actions within the last 12 months.
Consent
(Required)
I understand that Cheyenne Regional reserves the right to amend or terminate the offering of the Employee CareFund program, at any time.
Consent
(Required)
I understand the maximum benefit paid is $3,000 within three (3) years from the date of application.
Consent
(Required)
I understand that funds from the Employee CareFund Program pays approved expenses directly to the creditors (except for groceries or gasoline).
Consent
(Required)
I understand that this is not a contract of employment, and that all employment with Cheyenne Regional is voluntary and at-will, meaning that I or Cheyenne Regional have the right to terminate the employment relationship at any time, for any reason or no reason, and that this agreement does not alter that at-will employment relationship.
Quick Menu
Staff / Employees
Benefits and Wellness
2025 Payroll Calendar
How to File a Leave of Absence
2024 Open Enrollment Required Notice
Employee Discounts
Wellness Program FAQs
Employee CareFund Program Application
Employee Hardship Loan Application
2024 Benefits
Haiku/Canto
Healthstream
Internal Job Postings
UKG Login
On Call/LCD Form
Page load link
Go to Top
Notifications