HIGH FIVES FOUNDATION | Empowerment Fund Grant Application

Demographics

First Name

Last Name

Email

Phone Number

Physical Address

Unit/Apartment

City

State

Zip Code

Country

Is your physical address the same as your mailing address?

YesNo

Mailing Address

Unit/Apartment

City

State

Zip Code

Country

Date Of Birth

Month

Day

Year

Age

Are you a Military Veteran

YesNo

Race & Ethnicity (collected for statistical purposes)

Please select the option(s) you identify with most.

Adjusted Gross Income (reported on previous year's tax returns)

Less than $15,000$15,000 - $30,000$30,000 - $60,000More than $60,000

Application Guidelines

Do you live in North America?

YesNo

Do you have current and up to date health care coverage or are covered by national coverage?

YesNo

Is your condition the result of a medical condition or degenerative disease?

Yes No

How many times have you applied for a High Fives Foundation Empowerment Fund Grant?

This is my first time applyingThis is my second time applyingThis is my third time applying This is my fourth or more time applying

Were you approved or denied?

ApprovedDenied

Date of last grant award (MM/DD/YYYY)

Thank you for reaching out to the High Fives Foundation. Unfortunately, you are not eligible for an Empowerment Fund Grant as applicants must live within the United States or Canada, and must have current health care coverage. Check out this list of supporting organizations that you might qualify for instead -> SUPPORTING ORGANIZATIONS

I understand

INJURY INFORMATION

Date of Injury

Month

Day

Year

Age at time of injury

Please provide a DETAILED description of the extent of your injury and how it occured.

Please upload a copy of your DD214

Type of Injury

Spinal Cord Injury Type

Complete ParaIncomplete ParaComplete TetraIncomplete Tetra

Spinal Cord Injury Level (select all that apply)

C1-C7T1-T6T7-T12L1-S1

Did you spend time in the ICU?

YesNo

How many days were you in the ICU?

Name of ICU Hospital

Did you spend time in in-patient rehab?

YesNo

How many days were you in in-patient rehabilitation?

Name of in-patient rehabilitation

Goals

Please thoroughly describe your recovery goals.

FUNDING

Please select the funding categories you would like to apply for (Select all that apply)

Based on your information you can apply within the following funding category

Adaptive Equipment

Please select the adaptive sports equipment you would like to apply for. (Select all that apply)

Adaptive Mountain Bike Equipment Adaptive Surf Equipment Adaptive Snow Equipment Adaptive Dirt EquipmentAdaptive Fly Fish Equipment Other (pre-approved by Director of Programs as special exception only)

Who did you speak with for special exception?

Roy TuscanyDani Trujillo

Please provide a brief description of the item and/or services you are requesting funding for.

What is the ESTIMATED cost of the item and/or services that you plan to request funding for?

ADDITIONAL INFORMATION

What is your social media handle(s)?

Have you ever been a paid professional in your sport?

YesNo

Please list any companies/brands that have supported you.

Please upload a photo(s) of yourself that best represents who you are.

WAIVER & TRUTH STATEMENT

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

I Agree