Path2Active Application

Part 1 - General Information

This is the section where we learn the details about you and your cause of paralysis.

Name of Applicant*

First Last

Are You the Applicant?*

Yes
No

Your Name*

First Last

Relationship to Applicant*

Reason Applicant Cannot Submit Application for Him/Herself*

The Applicant MUST fill out the application him/herself unless under the age of 13 or his/her disability prevents use of a computer. Regardless, applicant must be aware of and consent to all answers.

Date of Birth of Applicant*

Email*

Phone Number*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Facebook Name (if any)

Twitter Handle (if any)

Instagram Handle (if any)

Cause of Spinal Cord Injury*

Level of Injury*

Complete or Incomplete SCI*

Complete SCI
Incomplete SCI

Date of Injury*

Please explain your functionality at your level of injury. For example, describe use of hands, arms, torso, and leg muscles.*

Medical Documentation of Paralysis*

Please upload medical documentation on letterhead from your treating or primary care provider stating date and nature of your cause of paralysis.

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 16 MB, Max. files: 8.

Part 2 - Equipment and Participation Information

What Path2Active Partner Program are you applying through?*

We have several partnerships with programs around the country. Please help us by identifying which program you have attended.

Type of Equipment you are applying for*

Handcycle (Road)
Handcycle (Offroad)
Monoski
Other

Other:

Equipment Model*

For Example, if you are applying for a handcycle, please list the name of the model, such as "Top End - Force 3".

How many times did you visit the Path2Active Partner Program and use the equipment?*

Please enter a number from 0 to 20.

Have you tried similar equipment elsewhere?*

Yes
No

If yes, please list all other models and types you have tried.*

Why did you like the specific piece of equipment you are applying for?*

Please include the reason you liked this equipment more than others you have tried.

Vendor Quotes*

Drop files here or

Max. file size: 6 MB.

Please provide 2 personalized quotes from adaptive sports equipment vendors for your desired equipment. If only one vendor manufacturers the desired equipment, you may upload only 1 quote.

Part 3 - Financial Information

This is the section where we learn about your financial situation.

Annual Household Income*

Sources of Household Income (select all that apply)*

Own Employment
Spouse's Employment
Parent's Employment
SSI
Annuity
Other

Other Source of Income

Financial Documentation

Must be sent to [email protected] or mailed to Three Main Street, Suite 217, Burlington, VT 05401.

Part 4 - Personal Questions

This is the section where we learn about YOU!

How did you learn about the partnership between the KBF and the Path2Active Partner Program?*

Have you ever applied for a grant from the Kelly Brush Foundation?*

Yes
No

What year did you apply?*

Were you awarded a grant by the Kelly Brush Foundation*

Yes
"Try if First" grant
No

What are the limitations on your use of this equipment? Specifically storage, transportation, health, transferring, etc.*

Have you tried any other adaptive sports?*

Yes
No

What sports have you tried and how frequently and where have you participated in them (ie. at an adaptive sports program, demo center, renting, or borrowing)?*

Do you currently own any adaptive sports equipment?*

Yes
No

What equipment and when did you obtain it? Did you receive any financial assistance in purchasing the equipment? If so, from who?*

Please explain how the equipment you are applying for would impact your life. Please include where and how often you hope to use the equipment.*

What else would you like the members of the Grants Committee to consider when reviewing your application?*

Photos

OPTIONAL - If you have any photos of you being active or generally having fun, or that give us a better sense of who you are as a person, please upload here!

Drop files here or

Accepted file types: jpg, png, Max. file size: 5 MB, Max. files: 3.

Certification*

By writing my name below, I hereby certify that all information included in this application is accurate, to the best of my knowledge, as of the date submitted.

Certification by Representative*

By writing my name below, I hereby certify that all of the information in this application is accurate as of the date of submission and that the Applicant has been informed of the responses to each questions, has consented to each of the responses, and understands that he/she will be responsible for being familiar with the Guidelines and Requirements as well knowledge of each response above.

Get Started:

Part 1 - General Information

Part 2 - Equipment and Participation Information

Part 3 - Financial Information

Financial Documentation

Part 4 - Personal Questions