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
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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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Applicants must request specific modifications or equipment. Eligible items include but are not limited to wheelchairs, exercise equipment, vehicle modifications, home modifications, adaptive equipment. It is up to the applicant to explain how this grant will improve their quality of life.
0/500
Amount of assistance you are requesting?
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Grants run on average $3,500, however, there is no minimum award.
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
File Upload
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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.
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Please Select
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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.
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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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