Adaptive Equipment Grant Application

Adaptive Equipment Grant Application
Basic Contact Info:
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
Phone Number
Diagnosis
Personal Statement
- Share your personal story, including your journey with your disability.
- Explain how sports and physical activity have impacted your life.
- Discuss challenges you’ve faced in pursuing your athletic goals.
- Share your long-term goals in sport and in life.
(Please provide 500-750 words).
Financial Statement

Our review team does consider socioeconomic status and applicants’ financial situation as a factor in grant eligibility. Please include either: last year’s tax return or a written statement about your financial situation
File Upload

Last years tax return (if applicable).
Cancelof
Equipment Request
1. Equipment you are requesting:
Be as specific as possible, including make/model if known.
2. Why is this equipment needed?
3. How will this equipment help you achieve your goals?
4. Have you tried this equipment before? If yes, describe your experience:
5. Total cost of equipment:
We can't always fund 100% of costs but are willing to provide partial funding.
Please attach quotes, estimates, or invoices.

Cancelof
6. Do you currently own any adaptive sports equipment? If so, what equipment and when did you obtain it? Did you receive any financial assistance in purchasing the equipment? If so, from who?
7. Have you received any other grants in the past 3 years?
8. Are you applying for any other grants this Fall?
9. Do you represent any other organizations or brands?
10. Do you have any additional funding sources? If yes, please list:
Athletic Goals
Which sport/s do you compete in?
What do you hope to accomplish with this piece of equipment?
Are you registered, or intend to register for any specific competitions in 2026?
How will this grant change your athletic journey or personal life?
How do you plan to use your platform as an adaptive athlete to inspire or support others?
If you are chosen as an AdaptX grant recipient, do you agree to include our logo on your competition gear or wear AdaptX apparel that we provide? (Logo on a singlet, sticker on a racing chair, etc.)

YesNo
Please explain why not:
If you are chosen as an AdaptX grant recipient, are you willing to share your story?

YesNo
Please explain why not:
Additional Information
Is there anything else that you would like our review committee to consider when reviewing your application?
Supporting Materials
Please submit a letter of recommendation from a coach, therapist, mentor, or community leader.

Required
Cancelof
Please include a current photo of yourself participating in sport.

Optional
Cancelof
Applicant Agreement

By signing below, I confirm that all information provided is true and accurate. I understand that grant funds must be used solely for the purchase of the adaptive equipment requested in this application.
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty:

Adaptive Equipment Grant Application

Basic Contact Info:

Equipment Request

Athletic Goals

Additional Information

Supporting Materials