High Fives Foundation | Access Unlimited Application

First Name

Last Name

First Name

Last Name

Physical Address

Street

Apartment / Unit

City

Zip / Postal Code

State / Province

Country

Mailing Address

Street

Apartment / Unit

City

Zip / Postal Code

State / Province

Country

Date Of Birth

Month

Day

Year

Age

Race & Ethnicity (collected for statistical purposes)

Date of Injury / Disability

Month

Day

Year

Age at time of Injury / Disability

Please provide a DETAILED description of the extent of your disability, or impairment, and a history of it's onset.

Additional Considerations, or Support Needs: Please let us know if there's anything we can do to better support your participation or medical needs. This may include information about sore or sensitive areas, medical devices, required medications ( e.g., for allergies or seizures), motion sickness, or other relevant conditions. (N/A for Not Applicable)

Have you ever suffered from Autonomic Dysreflexia?

YesNo

Why are you a great fit for an Access Unlimited experience? Tell us why you think you would have a rad time with Access Unlimited.

What do you seek to gain from an Access Unlimited camp?

Thoroughly describe your goals in life. What are your short term, long term, and ultimate goals?

Waiver & Truth Statement

THE STATEMENTS AND ANSWERS GIVEN IN THIS GRANT APPLICATION ARE TRUE AND CORRECT. I UNDERSTAND THAT MISSTATEMENTS IN THIS GRANT APPLICATION COULD CAUSE MY APPLICATION TO BE DENIED. THE HIGH FIVES FOUNDATION RESERVES THE RIGHT TO DENY APPLICATIONS BASED ON DISCRETION.

I Agree