Haven membership subsidy request form for May

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What is your name? *

What is your email address? *

What is your membership level? *

Community Ally

Social

Part-time

Full-time

Couple

Team

Weekend Only

Nights & Weekends

What level of subsidy are you requesting for May? *

25% off your current membership

50% off your current membership

75% off your current membership

Other:

What type of worker are you? *

Entrepreneur

Small business owner

Independent contractor/ consultant

Remote employee

Non profit employee

Other:

What type of business loss have you experienced? *

This is for aggregate purposes only - we are getting asked about the financial impact on our members from outside sources and would like to have a sense of how this crisis is impacting our membership.

I was laid off temporarily

I lost my job permanently

I have taken a pay cut

I am a small business owner and my business is temporarily closed

I am a small business owner and my business is still open but revenue has decreased

I am a contractor/consultant and my revenue has decreased

Other:

Any additional questions or comments?

Please type your name to certify that you are experiencing financial strain during this time and need a temporary subsidy in order to continue your Haven membership, and that you understand that you will need to reapply for a subsidy each month.

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