Adapted Van Giveaway Application

Triumph Foundation’s Adapted Van Essay Contest will select a person with Spinal Cord Injury to receive a donated wheelchair accessible van. There are many individuals that cannot afford a modified vehicle to go to work or school, regain family unity, and/or simply reintegrate back into the community. Triumph Foundation’s Adapted Van Giveaway Essay Contest seeks to find an individual who can most benefit for receiving the adapted van to help them reclaim their freedom and independence.
• To be considered, applicants must complete all questions on this application, including the essay section, and uploading a picture of yourself.
• Applicant Qualifications:
- California resident with a Spinal Cord Injury
- Require the van’s special features
- Available to personally receive vehicle upon being awarded
- Provide insurance at time of receipt
- Proof of income/financial constraint
- Must be 18 years or older
- Agree to participate in Triumph Foundation press and promotions regarding the Adapted Van Giveaway Essay Contest
Name*
First Last
Date*
Month
Day
Year
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
DOB*
Month
Day
Year
Gender*
Race/Ethnicity*
Are you a Veteran?*
Are you a citizen of the United States?*
Disability Type*
Date of injury/diagnosis*
Month
Day
Year
Injury Level/Description*
Cause of injury*
Do you live in Southern California?*
Do you have your driver's license?*
Do you have the certification for hand controls?*
Do you drive from your wheelchair?*
How did you hear about the Adapted Van Giveaway Essay Contest?*
Essay*
Upload a picture of yourself*
Accepted file types: jpg, jpeg, png, gif.
Upload a picture of yourself