Grant Applicant Application

Form
Bernie’s Pura Vida Grant Application
Applicant’s Name

First NameLast Name
Applicant’s Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
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?)

YesNo
Does the applicant have an adult able to travel with them to assist with personal care and medical care?

YesNo
Please describe the applicant’s physical disability.
What adaptive equipment does the applicant use?

Manual wheelchairElectric wheelchairCrutchesWalkerBracesProsthetic limb(s)ScooterOther
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 bifidaEpilepsyOEIS Complex/Cloacal ExstrophyAdopted from foster careCurrently in foster careAged out of the foster care system
Additional Participant 1

First NameLast Name
Additional Participant 1 Date of Birth

MonthDayYear
Date
Additional Participant 2

First NameLast Name
Additional Participant 2 Date of Birth

MonthDayYear
Date
Additional Participant 3

First NameLast Name
Additional Participant 3 Date of Birth

MonthDayYear
Date
Additional Participant 4

First NameLast Name
Additional Participant 4 Date of Birth

MonthDayYear
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

MonthDayYear
Date
Preferred week of travel 2

MonthDayYear
Date
Preferred week of travel 3

MonthDayYear
Date
I am aware that airfare is not included and only the applicant’s cost are covered

YesNo
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.

YesNo
I understand that my medical provider must certify that I meet criteria and it is safe for me to travel.

YesNo
Please upload the medical provider form

Cancelof
Please upload a photograph of the applicant

Cancelof
Should be Empty:

Form

Bernie’s Pura Vida Grant Application

Preferred Travel Dates