Chair Force 1 Foundation Application

Applicants will NOT be chosen on a first-come first-serve basis.

Applications will be accepted contingent upon available resources, pre-existing commitments and by committee.

Criteria

The recipient must have the current need of a wheelchair, must be a primary caretaker or dependent of someone using a wheelchair.

Special attention to Neurological Disease (The primary community we serve is the ALS community)

Priority given to wheelchair accessible van needs over other medical equipment or financial needs.

Priority given to permanent wheelchair need over temporary need

First Name

Last Name

Email

Phone Number

First Name

Phone Number

Last Name

Email

Date of Birth required

Address

City

State

Zip

Does the person requesting assistance have ALS? If not please explain.

Please describe the person requesting assistance's current level of mobility. (Walking, cane/walker, power wheelchair, etc.)

How did you hear about Chair Force 1 Foundation?

Do you have any minor dependents?

If you have school age children please include school details (name, do you pay tuition and if so how much).

Are you involved as an active member in your community with other non-profits, Churches, other causes? If so please provide details.

Have you requested help from other non-profits? Please list or let us know who as helped.

What else should our organization know about your situation, family, and current needs?

Thanks

Thank you for your application.

A member of the Chair Force 1 team will be in touch soon.