Craig TBI App - Kelly Brush Foundation

Part 1 - General Information

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

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*

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)

Mobility*

Ambulatory
Wheelchair

Cause of Traumatic Brain Injury*

Date of Injury*

Discharge Date (Month/Year) from Craig Hospital:*

Please explain any physical or cognitive limitation you experience due to your TBI. For example, weakness on one side, visual deficits, memory, balance, etc.*

Have you ever applied for a grant from Craig Hospital?*

Yes
No

Were you awarded a grant by Craig Hospital?*

Yes
No

When did you receive a grant from Craig Hospital?*

Part 2 - Equipment and Participation Information

This is the section where we learn about the piece of adaptive sports equipment you hope to purchase.

Type of equipment you are applying for:*

Equipment Model*

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

Total Cost of Equipment:*

Please input the lower amount of the two quotes provided.

Have you tried the type of equipment that you are applying for?*

Yes
No

How many times have you tried the type of equipment, what model(s) have you tried, and where have you tried them?*

Please be specific about the brands and models you have tried and where you were able to use it (adaptive sports program, borrowing, etc.).

If not, please explain why you want this type and model of equipment.*

Why are you applying for this specific model of equipment?*

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

If granted this equipment, would you be able to store it, transport it if necessary, and use it independently? What limitations might there be for you using the equipment?*

Amount of Funding Requested:*

We recommend that each applicant consider a personally meaningful contribution toward their piece of equipment, as able, to represent their commitment or if you have already received some funding, please indicate remaining funding needed. If not, please indicate Total Cost.

Name of Vendors of Uploaded Quotes:*

Vendor 1	Vendor 2

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 manufactures 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 Donna at [email protected] or mailed to Donna Goldberg, Therapeutic Recreation, Craig Hospital, 3425 S. Clarkson St., Englewood, CO 80113 and RECEIVED before the monthly deadline.

Have you applied for any other grants or other financial assistance to acquire this piece of equipment?*

Yes
No

What organization?*

How much did you apply for?*

What is the application's status?*

If you received an award, please list the amount and date.

Part 4 - Personal Questions

This is the section where we learn about YOU!

How did you learn about the the grants available from Craig Hospital?*

Have you tried any other sports since your TBI?*

Yes
No

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

Do you currently own any adaptive sports equipment?*

Yes
No

What equipment do you have 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, how often, and with whom 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.

Recommendation

OPTIONAL -If available, please include any letters of recommendation from family, Craig therapists, friends, coaches, etc.

Drop files here or

Accepted file types: jpg, png, pdf, 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 content of each response above.

Craig Hospital TBI Application

Part 1 - General Information

Part 2 - Equipment and Participation Information

Part 3 - Financial Information

Financial Documentation

Part 4 - Personal Questions