Quality of Life Grant Application

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Preferred phone*

Preferred email*

Date of Birth*

Who invited you to apply to this invitation-only application? How did you learn of the Travis Roy Foundation?*

Have you been awarded a grant from the Travis Roy Foundation in the past?*

When were you awarded the grant and what equipment/modification did the grant fund?*

Date of Injury*

Highest level of spinal cord vertebra injured*

Please describe what caused your spinal cord injury and provide any relevant details surrounding the incident.*

Are you working with a social worker?*

Social worker's name

Social worker's phone number

Social worker's email

Are you able to walk on your own or with assistance (such as with a cane, walker, or crutches?*

Please describe the physical abilities you lost as a result of your spinal cord injury. What mobility do you have now?*

Please share how your spinal cord injury has changed your ability to work, socialize with friends and family, and live an independent life?*

Have you received a settlement or compensation as a result of your injury?*

Please explain, providing details about the permitted use of these resources.*

Describe your sources of financial support and typical expenses (please note: grant recipients may be asked to provide supporting documentation such as tax returns or letters of determination).*

Please explain whether or not you have tried to obtain coverage for this equipment or modification through insurance.*

Describe additional resources, means, or methods you have pursued or will pursue to fund your request.*

Equipment or modification you are applying for*

*

The Travis Roy Foundation has a trusted partnership with Numotion for adaptive equipment such as wheelchairs, wheelchair accessories/modifications, patient lifts, wheelchair lifts, and bath & toilet equipment . Would you like to be connected with an Assistive Technology Professional for an evaluation and estimate? Your application will be considered complete following Numotion's evaluation.*

In Massachusetts, the Travis Roy Foundation has a trusted partnership with Lifeway Mobility for the purchase of ramps. Would you like to be connected with a professional Lifeway representative for an evaluation and estimate? Please note that if you choose to go through Lifeway Mobility, your application will be considered complete once we receive their estimate.*

Please give a brief explanation of how the equipment or modification(s) you are applying for will improve your daily life*

What professional help did you have to make sure this equipment or modification is appropriate for your specific needs or circumstances?*

If the equipment or modification you are applying for is a permanent fixture (i.e renovations, ceiling track system, concrete ramp, etc.), please share 1.) How long you have lived at this residence, 2.) How long you expect to live in this residence, 3.) If you own or rent this property, and 4.) If you do not own your residence, who owns the home that will be modified? Have you been granted permission for such alterations (You may be asked to provide documentation from the property owner that permission has been granted to alter their property)?

Grant amount requested*

Maximum award is $5,000

Total cost of project or item*

The maximum award we grant is $5,000. If the cost of the equipment/project you are requesting exceeds $5,000, please explain how you might cover the remaining expense (please note that due to the imminent closure of the TRF, grants must be redeemed by April 2023, which may provide you with some time to seek out additional resources).

Other factors that you wish to be taken into consideration (health factors, living arrangements, financial or family issues etc.):

In order to be considered for a Travis Roy Foundation Quality of Life Grant, applicants must provide estimates for the cost of the equipment or renovations requested. Incomplete applications will not be considered.

Please provide the names, addresses and phone numbers of at least two (2) companies and/or contractors you have contacted and their estimates for the equipment or modifications requested. We ask for at least two estimates to ensure that you have shopped around for prices and that we will be paying a fair market value. If only one vendor manufacturers the desired equipment, you may upload only 1 quote. Applicants who have requested that the Travis Roy Foundation connect them with Numotion, or for Massachusetts residents, Lifeway Mobility, only need to submit one vendor quote with this application.

Estimate #1

Company & Contact Name

Address

Street Address City State ZIP Code

Phone

Website

Price Quoted

Please upload a vendor-provided estimate, quote, or proposal here

Estimate #2

Company & Contact Name

Address

Street Address City State ZIP Code

Phone

Website

Price Quoted

Please upload a vendor-provided estimate, quote, or proposal here

*

I certify that, to the best of my knowledge and ability, the information included in this application is accurate as of the date signed below. I also acknowledge that I am aware that if I receive a Travis Roy Foundation grant, my name/image may be used by the Travis Roy Foundation for media and/or promotional purposes

Your typed name indicates your signed consent*

Date*

TRF: Quality of Life Grant Application

Estimate #1

Estimate #2

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