I AM’s Wellness Grant Application

Name*

First Last

Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County of Residence*

Email*

Enter Email Confirm Email

Phone*

Briefly describe the nature of the service that would be supported under grant funding. Please include specific details, such as: experience level participating in activity (never before, routinely, etc.), how often you will engage in activity (once a week, monthly, etc.), equipment or professional services to be used.*

Why do you want to pursue this activity and what are your expected outcomes from participation? Please include specifics, such as: increased fitness, mental wellbeing, etc.*

All funds will be mailed to the address as designated on the application with the check made payable to the provider, except in the case of reimbursement where a check will be sent to the individual after providing proof of expenses. Please provide the following information:

Name of Facility:*

Address of Facility:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Contact Person (If Applicable):

Contact Person/Facility Phone Number (If none applies put N/A):

I would prefer to deliver the facility payment in person, rather than have us mail it to them.

Yes

I will be seeking reimbursement after submitting the necessary receipts/documentation.

Yes

What is the cost for the service for which you are seeking support?

$*

Is this a:*

Recurring monthly cost
Fixed one-time cost
Per session/Per visit cost

What percentage of the service cost would you like covered?

Note: Requests for up to 75% of costs in a calendar month will be considered with a total award amount not to exceed the maximum of $500.00. Eligible expenses include costs associated with activities that promote physical movement. These include memberships, user fees, personal training, as well as expenses related to the pursuit of sports such as equipment rental, lessons, and costs related to events in which the applicant participates. Also covered are holistic practices such as counseling, meditation training, nutrition counseling, massage therapy, and acupuncture. Excluded expenses include the purchase of equipment, any kind of physical or occupational therapy, or medical treatment. If you are unsure if expenses are eligible, please use the space provided to make the request and include justification.

Please indicate how you wish to submit receipts and forms as part of the reporting process:*

Using I AM’s website
By mail, using paper forms

Note: the following information will only be used for the purposes of program assessment and to describe program participants as a group. This information will have no bearing on grant awards. No individual information will be shared with outside entities.

Age:*

Sex:*

Racial/ethnic identity:*

Employment Status:*

Occupation:*

Physical Impairment:*

Only upper extremity impaired
Only lower extremity impaired
Upper and lower extremities impaired

I confirm that I have read, understand, and agree to honor the terms and conditions outlined in the grant guidelines and will use any grant money only for the purpose for which it was intended.*

Yes
No

I confirm that I am a member of Individual Abilities in Motion.*

Yes
No

I confirm that I will participate in a minimum of one I AM activity or meeting over the course of the grant period.*

Yes
No

I confirm that I will participate in fund-raising for I AM in some capacity as outlined in the grant guidelines.*

Yes
No

I consent to allow I AM to use any photos submitted for promotional purposes.

Yes
No

By typing my name below, I confirm that this is an electronic signature and thereby consent to the terms and conditions of the grant.*

First Last

Thank you for taking the time to fill out the application! We will review the information provided and get back to you regarding its approval status. Please feel free to contact us if you have any questions.

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I AM’s Wellness Grant Application