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Uncertainty Fund Request Form

Slought is making $10,000 available to our extended community for mutual aid. Current and former staff, as well as artists, activists, and those with whom we have directly worked on past projects, are invited to seek aid. We hope these funds, though modest, will be helpful to our colleagues who are vulnerable at present.

Requests and disbursements will remain confidential and multiple requests are permitted as circumstances change. Requests for aid in amounts ranging from approximately $50 to $300 will be disbursed in the order they have been received until all funds have been distributed.

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<label>Contact Information</label>

<div class="field-row">
<input type="text" id="form-name" name="name" placeholder="First Name Last Name" value=""/>
</div>

<div class="field-row">
    <input class="narrow" type="text" name="email" placeholder="Email Address" value="" />
    <input class="narrow" type="text" name="phone" placeholder="Cell Phone" value="" />
</div>

<div class="field-row spaced">
<label for="form-involvement">In what capacity and during which year(s) were you involved with Slought?  </label>
<textarea id="form-involvement" name="involvement" cols="20" rows="3"></textarea>
</div>

<div class="field-row spaced">
    <div class="field-block narrow">
        <label for="form-applicant">Are you applying for yourself or for someone else (for example, a collaborator you worked with on a project)?</label>
        <input type="text" id="form-applicant" name="applicant" placeholder="e.g. Myself, John Doe" value=""/>
    </div>

    <div class="field-block narrow">
        <label for="form-amount">What is the amount of your request?</label>
        <input type="text" id="form-amount" name="amount" placeholder="e.g. $50-300" value=""/>
    </div>
</div>


<div class="field-row spaced">
        <label for="form-alternative_address">If you would like checks to be sent to a different address than the one listed on your W9, please provide another address here.</label>
        <input type="text" id="form-alternative_address" name="alternative_address" value="" />


<div class="field-row spaced">
<label for="form-other_information">Is there anything you would like us to know about your situation or your request? This information will not be used as a determinant of who receives aid.</label>
<textarea id="form-other_information" name="other_information" cols="50" rows="3"></textarea>
</div>

<div class="field-row spaced">
<label for="form-documents">Please complete and <a href="mailto:info@sloughtfoundation.org">email us</a> a signed memorandum and W9 form. Checks will be mailed to the address listed on the forms, which you can <a href="/media/files/s759-pandemic-uncertainty-fund_memorandum_of_understanding.pdf" target="_blank">download here</a>.  Have you completed this step?</label>
<input type="radio" name="documents[]" value="Yes">Yes
<input type="radio" name="documents[]" value="No">No
</div>

<div class="field-row spaced">
</div>
<button class="button" type="submit">Submit</button>