CARE – CHECKERS & RALLY’S EMPLOYEE RELIEF FUND

CARE – CHECKERS & RALLY’S EMPLOYEE RELIEF FUND

CARE is a nonprofit charity funded through the generous donations of Checkers/Rally’s corporate office and voluntary donations from Checkers/Rally’s employees, franchisees, and supplier partners.

CARE is designed to assist eligible Company and Franchise employees who face hardship due to natural disasters, personal tragedies, or other events beyond their control.

Employee's Name:*

Please provide your full legal name as it appears on your state-issued identification.

Company or Franchise Location:*

Select or enter value

Restaurant # or Department:*

Employee ID # (if applicable)

Start Date: *

Position:*

Average Hours per Week: *

Current Mailing Address: *

City: *

State:*

Zip:*

Phone Number: *

Phone

E-mail: *

Please provide a valid email address for further information.

Please explain the situation & urgency of request*

Please explain financial need.*

Please enter amount requested*

Date of Emergency:*

Fire or Police Dept. Responding (if any):*

Select

Will insurance cover or assist with the loss?*

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Additional comments for insurance coverage.

Is this your first application to CARE? *

Select or enter value

Date of prior request?*

Please attach any supporting documents or pictures here.

Drag and drop files here or

Print name acknowledging you have read Declaration

DECLARATION:

By this form, under penalty of perjury, I declare, to the best of my knowledge and belief, the above stated information is true and correct. I authorize Checkers Drive-In Restaurants, Inc., its affiliates, and assigns ("Checkers") to disclose any confidential or financial information to the application review committee as it pertains to the above emergency. I also grant to Checkers the absolute and irrevocable right and unrestricted permission concerning any confidential or financial information provided by me or any video or photographs that Checkers has taken or may take of me or in which I may be included with my application, to use, reuse, publish, and republish the information, video or photographs in whole or in part, individually or in connection with other material, in any and all media now or hereafter known, including the internet, and for any purpose whatsoever, specifically including illustration, promotion, art, editorial, advertising, and trade, without restriction as to alteration; and to use my name in connection with any use if Checkers so chooses. I release and discharge Checkers from any and all claims and demands that may arise out of or in connection with the use of the information, videos, or photographs, including without limitation any and all claims for libel or violation of any right of publicity or privacy. This authorization and release shall also inure to the benefit of the employees, corporate successors, legal representatives, licensees, and assigns of Checkers, as well as the person(s) who took the video or photographs. I am a legally competent adult and have the right to contract in my own name. I have read this document and fully understand its contents. This release shall be binding upon me and my heirs, legal representatives, and assigns.

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