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I AM’s Wellness Grant Application
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R.E.A.C.H.
I AM’s Wellness Grant
I AM’s Wellness Grant Application
I AM’s Wellness Grant Application
admin
2023-02-05T16:20:22-05:00
I AM's Wellness Grant Application
(January 1st, 2023-December 31st, 2023
Name
*
First
Last
Date
*
MM slash DD slash YYYY
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
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
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
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
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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