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Kiel Program Application Form

To apply to receive donations from the Kiel Program, please complete the Kiel Program Application Form below along with a Certification of Health Care Provider Form*. The Kiel Program Application Form is submitted to your supervisor and payroll representative, and then forwarded to Benefits for processing. The Kiel Program Application Form should be sent to Duke Benefits:
Mail:705 Broad Street (Box 90502)
Durham, NC 27705

In order to ensure that submitted forms are processed in time for payroll cutoff schedules, all documents (applications, certifications of health care providers, and donations) will need to be submitted to the Duke Benefits (see above) no later than noon on the cutoff dates listed here. Final approval by Benefits is required.

*See also the Certification of Health Care Provider Forms for employees and/or family members.


Benefits - Work Absences, Kiel Program