Survivor Adaptive Sports Fund Application

Adaptive Sports Fund Application: Biographical Information

Please select *

Permanent disability (i.e. spinal cord injury, amputation, vision impairment, traumatic brain injury, nerve/muscle damage that permanently impedes function)

First Name *

Last Name *

Gender *

Date of Birth (mm/dd/yyyy) *

Address *

Apt, suite, etc.

Country

City

State

Zip code

Cell Phone *

Email Address *

T-Shirt Size *

Disability Information

Disability *

Please be as specific as possible

Date of Injury *

(mm/dd/yyyy)

Cause of Injury *

Please provide an explanation on how you were impacted by a natural disaster or tragic event. Include links to news articles if available.

File Upload *

Upload physician’s note and/or pictures/video to demonstrate and verify impact of natural disaster or tragic event.

Sports Information and Goals

If other, please specify

Event or Program Name *

Be specific: i.e. four golf lessons

Event or Program Dates

If applicable

Describe your skill level in the sport *

Do you use or will you require adaptive equipment for this activity? *

I am unsure

Yes

If yes, please describe

Are you currently receiving training or equipment grants for other sources? If so, from where and how much? *

Funding Requested *

Please be specific, i.e. $60 per lesson for 8 lessons =$480

Please provide an explanation of how these funds will positively impact your future athletic or fitness goals. *

Please provide an explanation of your goals in this sport or activity. *

Overall budget for your participation. Please enter a total dollar amount for each category.

Entry or Membership Fee

i.e. event registration

Coach/Instructor Fee

License or Facility Fee

i.e. lift ticket

Airfare

Ground Transportation

i.e. mileage, gas or rental

Lodging

Adaptive Equipment / Other

Are you willing to accept a partial grant? *

Please note that grants are awarded as available funds permit. Selecting that you are interested in a partial award may increase your chances of receiving funds.

Submit

You should receive a confirmation notification to the email address submitted in your application. If you do NOT receive a confirmation, please contact BreAnne Podgorski at bpodgorski@dsusa.org to confirm your submission was received for review.

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Survivor Adaptive Sports Fund Application