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Adapted Van Giveaway Application
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
*
Email
*
DOB
*
Month
Day
Year
Gender
*
Gender
Male
Female
I choose not to disclose
Race/Ethnicity
*
Race/Ethincity
African American
Caucasian
Asian
Hispanic/Latino
Native America/Alaskan Native
Pacific Islander/Native Hawaiian
Middle Eastern
Multiple Races
Other
Are you a Veteran?
*
Are you a Veteran?
Yes
No
Are you a citizen of the United States?
*
Are you a citizen of the United States?
Yes
No
Disability Type
*
Disability Type
Paraplegia
Quadriplegia
Spinal Cord Injury
Spinal Cord Disorder (TM/GB/Polio)
Spina Bifida
Stroke
Amputee
Cerebral Palsy
Multiple Sclerosis
Muscular Dystrophy
TBI
Other
Date of injury/diagnosis
*
Month
Day
Year
Injury Level/Description
*
Cause of injury
*
Cause of injury
Vehicular
Fall
Violence
Sports/Recreation Activities
Medical/Surgical
Disease/Disorder
Cancer
Congenital
Other
Do you live in Southern California?
*
Do you live in Southern California?
Yes
No
Do you have your driver's license?
*
Do you have your driver's license?
Yes
No
Do you have the certification for hand controls?
*
Do you have the certification for hand controls?
Yes
No
Not yet, but I've started the process
Do you drive from your wheelchair?
*
Do you drive from your wheelchair?
Yes
No
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