1. Applicant Information (Information about the person completing this form)

By checking this box, I confirm that I am more than 18 years of age

2. How did you hear about Ceridian Cares U.S.?


3. Recipient Information (information about the person who receives grant/benefits from the grant)


*Recipient is an employee or immediate family member of Ceridian

*immediate family member = spouse, domestic partner, parents, grandparents, stepparents, siblings, children and stepchildren of the Ceridian employee

Employee of Ceridian
Is recipient a U.S. citizen or permanent resident?

4. Request Type

5. Confirmation and Consent

By checking this box, I confirm that everything I have submitted is correct and true, and I agree that if any information provided is found to be false, Ceridian Cares U.S. will pursue all rights and remedies available at law or in equity, and I shall pay and reimburse all grants provided and any legal fees Ceridian Cares incurs in pursuing such rights and remedies.

By checking this box, I agree that if I or the recipient receive or become eligible for funding of this need through another source, I have an obligation to notify Ceridian Cares U.S. and withdraw this application for grant and/or return any grant already awarded.

By checking this box, I confirm that I have obtained the consent of the recipient to provide Ceridian Cares U.S. the personal information within this submission (including but not limited to any financials and medical supporting documentation)

By checking this box, I hereby authorize Ceridian Cares U.S. to collect, retain, and use the information provided to it in my capacity as applicant or potential grant recipient for the purposes outline herein and subject to the terms of Ceridian Cares US Privacy Policy and Privacy Notice.

6. Release and Waiver

I hereby release and discharge Ceridian Cares U.S. and its present and former affiliates, officers, directors, employees, volunteers, beneficiaries, agents, representatives, vendors, successors and assigns (collectively, the “Released Parties”), from any and all claims, actions, causes of action, suits, debts, dues, accounts, controversies or damages, including but not limited to all consequential and incidental damages, awards, demands, expenses, including attorneys’ fees, interest and costs, whatsoever in law or in equity, which I ever had, now have, or hereafter may have against the Released Parties, or any one of them, whether known or unknown, suspected or unsuspected, fixed or contingent arising out or based upon any facts, circumstances, actions or events occurring prior to the date hereof or existing as of the date hereof, including without limitation, the grant process and the use of any funds provided to me or my intended beneficiaries from the grant process.

I hereby acknowledge, agree and understand that Ceridian Cares U.S. acts solely as a third party funder and as such has no role in prescribing, recommending equipment, selecting a vendor/contractor and in the relationship between any grant recipient and any vendor/contractor.

I hereby acknowledge, agree and understand that Ceridian Cares U.S. is not responsible for any work, equipment or services purchased with any funds that may be provided by Ceridian Cares U.S. to the recipient or his/her intended beneficiaries. The recipient assumes full responsibility for all risks inherent in accepting funding from Ceridian Cares.

By checking this box, I agree to the Release and Waiver as described above.