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G.O.A.L.S., Inc.
Funding Application
Contact Information
First & Last Name:
Address:
City:
State:
Zip:
Email Address:
Phone Number:
Date of Birth:
Date of Rehab:
Location of Rehab:
Level of Injury:
Living Arrangements
Type of Medical Care
Statement of Need:
Intended Use of Funds:
Estimated Funds Needed:
Additional Comments:
Agreement
All requests should be consistent with the foundation's primary focus of providing spinal cord injured individuals with increased opportunities for achieving greater mobility and independence, improving access to the non-handicapped environment, and maintaining personal dignity.
Funding decisions will be based on the disbursement committee's perception of need and the amount of money available. The recipient should no longer be receiving rehabilitation services, either inpatient or outpatient, and have no other source of funding for the request. Requests by organizations or agencies for group activities will also be considered. Approved funds will be paid directly for services and not to individuals or organizations.
I understand the above and attest the information I have provided is accurate and that I, am not a minor, and/or am the legal guardian of applicant.
If legal guardian, please enter your full name:
I will allow my name and/or picture to be used in the foundation's distribution of information.
