Ian Burkhart Foundation - Fund Request
2025
Basic Information
Applicant Name
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Email
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Name of individual completing the application
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Relation to applicant
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Todays Date
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Day
Year
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About The Applicant
Date of Birth
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Month
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Day
Year
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How would you describe yourself?
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American Indian
Asian
Black/African American
Hispanic/LatinX
Mixed Race
Native Hawaiian/Pacific Islander
White
Prefer not to respond
Other
Injury Level
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Enter comments about your injury level here. (Optional)
Date of Injury
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Month
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Day
Year
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Cause of Injury
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Cause of Injury
Motor Vehicle Accidents
Falls
Acts of Violence
Sports and Recreational Injuries
Medical/Surgical Complications
Diseases
Other
How would you say your spinal cord injury affects your everyday life?
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0/500
Describe your current mobility or a day in life
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Please explain your functionality at your level of injury. For example, describe use of hands, arms, torso, and leg muscles.
0/500
Please describe your current financial support, including household income.
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Note: Preference given to those with higher need, supporting documentation may be required
0/500
Annual Household Income
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Sources of household income (select all that apply)
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Own Employment
Spouse's Employment
Parent's Employment
SSI / SSDI
Annuity
Other
Links to your social media
Not required but gives our grant team a better idea of who we are helping
How did you hear about the Ian Burkhart Foundation?
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Tell us a fun fact about yourself: Hobbies, interests, quirks, anything!
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0/500
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 add those here
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About Your Request
Describe the equipment or modification(s) you are applying for, including specific product models
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0/500
Amount of assistance you are requesting?
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Please provide the names, addresses, and phone numbers of at least two companies you have contacted for the equipment or modifications requested.
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You must provide estimates for the cost of equipment requested. Incomplete applications will not be considered.
0/1000
Quote Uploads
Multiple quotes are required for full consideration
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How would your request impact your daily life and improve your independence?
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Be sure to provide specific examples
0/500
Additional comments or other factors you wish to be taken into consideration by the grant team.
*
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Confirmation
I have read and understand the eligibility requirements.
*
Please Select
Yes
No
I certify that, to the best of my knowledge and ability, the information included in this application is accurate as of the date submitted.
*
Please Select
Yes
No
If awarded a grant the individual must supply the Foundation with pictures of equipment purchased and a description of how the grant enriched the individual’s quality of life, which may be used for promotional materials.
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Please Select
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No
Please verify that you are human
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