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Keep Moving Forward Grant Application

Triumph’s Keep Moving Forward Grant is for people with spinal cord injury that have inadequate health insurance coverage and financial hardship to receive necessary equipment and services that will help them triumph over obstacles they face and enhance their quality of life. Categories of qualified requests by priority:

Adaptive Equipment for Activities of Daily Living- ex: wheelchairs, commodes, etc.
Home Modifications- ex: ramps, bathroom remodel, widen doorways, etc.
Return to Work/Community- ex: vehicle modifications, assistive computer technology, etc.
Therapy/Recreational Activities- ex: rehabilitation services, armcycle, standing frame, gym membership, etc.

Maximum Grant Awarded is $2,000 when funds are available and are paid directly to the vendor (no cash assistance to individuals). Partial Payments toward larger items (i.e. vehicles) will not be considered unless all payments are already in place for the total amount. For example, if requesting $2,000 toward a $20,000 purchase, you must have already obtained $18,000 to complete the transaction. Funding priority is given to Southern California residents. Individuals applying for a grant must be a citizen of the United States of America. Individuals are only eligible for assistance every other year. In order to be considered, applicants must complete all applicable questions on the below application form.

All grant applications are reviewed by Triumph Foundation’s Board of Directors. Grant requests will be responded to via email within 30-60 days.

Application Form

Grants and Equipment

Name:

Email:

Phone:

Address:

Date of birth:

Date of your injury:

Level of injury:

Cause of injury:

How did you hear about the Triumph Foundation Individual Grant Program?:

Please write a bio that describes how you were injured, the degree of your disability and how it affects your everyday life, how you currently stay active, any other factors that you wish to be taken into consideration (health factors, living arrangements, family issues etc.), and how this grant, if awarded, will help you triumph:

What is your annual household income?:

Describe your sources of financial support:

Please upload a copy of two previous years of Federal Tax Returns or Proof of Income or SSI SSDI letter from Social Security:

Please upload letter from doctor verifying SCI:

Please upload a picture of applicant:

Amount of funding for which you are applying? (up to $2000):

Which program(s) are you applying for? Check all that apply:

Adaptive Equipment for Activities of Daily Living

Please give a detailed description of which you are applying. Please include the manufacturer’s name, model number (s), and any other additional information that will help identify the piece of equipment.:

Please upload quote for item/service requested:

Please give a brief explanation of how the equipment for which you are applying would impact your life:

Do you currently have this type of adaptive equipment?:

What is it?:

When did you purchase it?:

Did you receive any financial aid to purchase the equipment?:

Have you applied for any other financial aid in order to acquire this equipment or service?:

What did you apply for and from which organizations?:

What is the status of this/these application(s)?:

If granted this equipment, how often would you use it?:

What, if any, are the limitations to your use of this equipment?:

Additional comments:

Home Modifications

Please give a detailed description of which you are applying. Please include pictures, measurements, and any other additional information that will help us understand your accessibility needs:

Please give a brief explanation of how the home modification for wheelchair accessibility which you are applying would impact your life:

Please upload quote for item/service requested:

Have you gotten a quote from a contractor?:

How much is it?:

When did you receive it?:

Do you own the house or residence?:

If not, who owns the property?:

How long do you plan to live there?:

Have you applied for any other financial aid to help with the construction costs?:

What did you apply for and from which organizations?:

What is the status of this/these application(s)?:

If given access, how often would you use it?:

What, if any, are the limitations to your use of this equipment?:

Additional comments:

Return to Work/Community

Please give a detailed description of which you are applying. Please include your goal(s), what type of barriers you are facing to pursue it further, what our assistance will enable you to accomplish, and any other additional information that will help identify the piece of equipment:

Please upload quote for item/service requested:

What, if any, are the limitations to your reintegrate back into the workforce/community following our assistance?:

Please give a brief explanation of how for which you are applying would impact your life:

Are you currently employed or going to school?:

Where?:

How Long?:

Please describe your 1 year, 5 year, and 10 year goals:

Have you applied for any other financial aid in order to acquire help?:

What did you apply for and from which organizations?:

What is the status of this/these application(s)?:

If granted how long until your goal is realized?:

Additional comments:

Therapy/Recreational Activities

Please give a detailed description of the type of the Exercise Program you are applying for. Please include the location, facility description, trainers name, brochure/resume, and any other additional information that will help us understand the training program:

Please upload quote for item/service requested:

Please give a brief explanation of how the equipment for which you are applying would impact your life:

Please describe your Therapeutic Exercise history, milestones, and goals:

Please describe your current training regiment? Please include your 1 year, 5 year, and 10 year goals:

Do you currently train in the program for which you are applying?:

How long have you been involved in the training?:

What is your schedule?:

What is your training goal?:

Did you receive any financial aid to get involved? If so, from what organization?:

If granted, how often would you attend?:

How do you plan to sustain your training program after the grants funds are exhausted?:

Have you ever applied for any other financial aid in order get this service?:

What did you apply for and from which organizations?:

What is the status of this/these application(s)?:

Additional comments:

Recreational Program

Please upload quote for item/service requested:

Please give a brief explanation of how the equipment for which you are applying would impact your life:

Please describe your Therapeutic Exercise history, milestones, and goals:

Please describe your current training regiment? Please include your 1 year, 5 year, and 10 year goals:

Do you currently train in the program for which you are applying?:

How long have you been involved in the training?:

What is your schedule?:

What is your training goal?:

Did you receive any financial aid to get involved? If so, from what organization?:

If granted, how often would you attend?:

How do you plan to sustain your training program after the grants funds are exhausted?:

Have you ever applied for any other financial aid in order get this service?:

What did you apply for and from which organizations?:

What is the status of this/these application(s)?:

Additional Comments:

I certify that, to the best of my knowledge and ability, the information included in this application is accurate:

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Timestamp

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January 11, 2022 4:51 pm PST

Keep Moving Forward Grant Application Uploaded by - IP 2600:8800:8024:100:447:3a8:c499:3f48

February 2, 2024 1:43 pm PST

Bobby Rohan - [email protected] added by Andrew Skinner - [email protected] as a CC'd Recipient Ip: 2600:8800:8008:ab00:b024:8ffb:1aac:8e73

April 25, 2024 9:42 am PST

Bobby Rohan - [email protected] added by patrick geyer - [email protected] as a CC'd Recipient Ip: 2600:8800:8024:100:e977:b801:e570:2d7f

May 16, 2024 12:10 pm PST

Bobby Rohan - [email protected] added by patrick geyer - [email protected] as a CC'd Recipient Ip: 2600:8800:8024:100:b1aa:b967:7980:3bf5

May 16, 2024 12:22 pm PST

Bobby Rohan - [email protected] added by patrick geyer - [email protected] as a CC'd Recipient Ip: 2600:8800:8024:100:b1aa:b967:7980:3bf5

May 16, 2024 12:43 pm PST

Bobby Rohan - [email protected] added by patrick geyer - [email protected] as a CC'd Recipient Ip: 2600:8800:8024:100:b1aa:b967:7980:3bf5