Grant Application

Grant Application Form

The completion of this application does not guarantee a grant for therapy. All information will be kept confidential. If you are among the finalists, you will be contacted for an interview.

Applicants can apply for a grant two different ways:

Printed Form – Download the Application Form. Fax the completed form to 734-953-1743.

Online Form – Complete the Online Application below and click Submit. You will receive an email confirming your submission.

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Contact Information

Full Name: *

Street Address: *

City:

State:

ZIP Code:

Email: *

Personal Information

Date of Birth: *

Sex: *

Height: *

Weight: *

Level of Spinal Cord Injury: *

ASIA Level/Score (If Known):

Diagnosis: *

Date of Injury:

How were you injured: *

At what hospital were you treated?

Treating Physician:

Current Physician:

Date of Last Medical Exam:

Past Surgeries:

Medications:

Describe present support systems (family, caregivers, etc.):

Emergency Contact Information

In case of emergency, please notify:

Name:

Relationship:

Home Phone:

Work Phone:

Ability Information

Describe your physical abilities (Be as specific as possible, particularly with respect to your legs):

Upper Extremities:

Trunk (IE: Can you sit up?):

Lower Extremities:

Please list any physical problems or special considerations (IE: osteoporosis/osteopenia, knee instability, obesity, hypersensitivity, rods in back, other health issues):

Previous Rehabilitation (if any):

Date last attended:

Results:

Insurance and Resources Information

Medical Insurance:

Physical Therapy Benefits:

Grant applications are considered for individuals that have no therapy benefits available from insurers (including Medicare) and are without personal resources to pay for therapy - please note the highlighted section from our mission statement:

While scientists, doctors and researchers around the world seek a cure for spinal cord and other neurological injuries, the responsibility of high intensity rehabilitation therapists is to keep those of us with SCI/TBI healthy and fit until a cure is found, or in a lifetime of fitness.

Unfortunately, there are injured individuals without the healthcare benefits or private resources for ongoing therapy and exercise.

The mission of The Mary and Charles A. Parkhill Foundation for Spinal Cord Rehabilitation is to raise funds that will be granted to those individuals, in the form of scholarships, to obtain therapy services.

Please describe your specific circumstances related to the availability of resources to fund physical therapy:

Insurance

Personal Resources (including Trust Information):

Can you pay any portion of the cost of therapy? *

If yes, how much per month:

Consideration Information

Please tell us your goals and aspirations, what you hope to achieve from rehabilitation: *

Why should you be considered for this grant: *

Recommendations Information

Please add your first letter of recommendation. *

No file chosen

Please add your second letter of recommendation. *

No file chosen

Certify Information

Full Name: *

Today's Date: *

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If under 18 years of age, name and date of parent or guardian:

Full Name:

Today's Date:

Relationship:

In order to sign this application electronically, please check the Captcha you see below:

By signing, I hereby certify all statements to be true. If found otherwise, I understand that all or portions of any grant can be forfeited.

Please do not fill in this field.

Grant Application