Form
Bernie’s Pura Vida Grant Application
Applicant’s Name
First Name
Last Name
Applicant’s Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
Please enter a valid phone number.
Email
example@example.com
Does the applicant have a primary PHYSICAL disability that would make travel to Costa Rica impossible without adaptive transportation, activities, lodging, and assistance? (Including but not limited to spina bifida, moderate to severe cerebral palsy, spinal muscular atrophy, spinal cord injuries, amputees, muscular dystrophy, etc?)
Yes
No
Does the applicant have an adult able to travel with them to assist with personal care and medical care?
Yes
No
Please describe the applicant’s physical disability.
What adaptive equipment does the applicant use?
Manual wheelchair
Electric wheelchair
Crutches
Walker
Braces
Prosthetic limb(s)
Scooter
Other
In case of limited funding, priority will be given to applicants in the following categories. Please select if the applicant fits any of the following categories in addition to the physical disability criteria.
Spina bifida
Epilepsy
OEIS Complex/Cloacal Exstrophy
Adopted from foster care
Currently in foster care
Aged out of the foster care system
Additional Participant 1
First Name
Last Name
Additional Participant 1 Date of Birth
-
Month
-
Day
Year
Date
Additional Participant 2
First Name
Last Name
Additional Participant 2 Date of Birth
-
Month
-
Day
Year
Date
Additional Participant 3
First Name
Last Name
Additional Participant 3 Date of Birth
-
Month
-
Day
Year
Date
Additional Participant 4
First Name
Last Name
Additional Participant 4 Date of Birth
-
Month
-
Day
Year
Date
Preferred Travel Dates
Please select your top 3 travel start dates. Please note these dates are not guaranteed and numerous factors go into finalizing travel dates.
Preferred week of travel 1
-
Month
-
Day
Year
Date
Preferred week of travel 2
-
Month
-
Day
Year
Date
Preferred week of travel 3
-
Month
-
Day
Year
Date
I am aware that airfare is not included and only the applicant’s cost are covered
Yes
No
I am aware that most commercial insurance does not cover medical expenses that occur out of country and that Medicaid never does. I will obtain appropriate travel insurance.
Yes
No
I understand that my medical provider must certify that I meet criteria and it is safe for me to travel.
Yes
No
Please upload the medical provider form
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Please upload a photograph of the applicant
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