G.O.A.L.S., Inc.
Funding Application
| Name: ____________________ |
Date: ____________________ |
| Address: ____________________ |
Phone: ____________________ |
| Address: ____________________ |
DOB: ____________________ |
| Location of Rehabilitation: _____________________ |
Date of Rehab: _____/_____/_____ |
Level of Injury ___________________
Living Arrangements (please describe):
|
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Statement of Need:
Intended Use of funds:
Estimated Funds Needed (please include quote if available):
Additional Comments:
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.
I understand the above and attest the information I have provided is
accurate.
______________________________________
(Signature)
______________________________________
(Parent's signature if a minor) I will allow my name
and/or picture to be used in the foundation's distribution of information.
______________________________________
(Signature)
______________________________________
(Parent's signature if a minor)
Please return to:
G.O.A.L.S., 7040 West Palmetto Park Road - Suite #4-679 - Boca Raton, FL 33433
or by Fax: (561) 516-6000
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