SCI Hope Fund Grant Request Form

Last Updated: June 23, 2010 | Today's date is

SCI Hope Fund
Champion Partners

Request the
SCI Hope Brochure -
CLICK HERE

Grant Request Criteria and Request Form

CRITERIA to recieve a grant

Applicant must be a former or current patient with Rehabilitation Hospital of Indianapolis (RHI), 4141 Shore Drive, Indianapolis IN 46254.
Applicant must be a spinal cord injury patient.
Applicant must complete and submit an SCI Hope grant form either by mail or submission through this website.
Applicant may be required to meet with the Executive Board (if additional information is needed) as part of the grant assessment.
Grant requests will be awarded based on fund availability.
Grant requests will be reviewed and awarded by the Executive Board after referrals made by RHI.
Awarded grants will be made payable to service providers.
Awarded grants will not be made payable to individual applicants.
Applicant will be notified by mail if grant request is approved or denied.

INSTRUCTIONS

To print the Grant Application you can mail or FAX to us - Click here
(Adobe Reader required) Download here

If you have questions or do not want to submit on-line, please contact us.

Please complete ALL FIELDS so we may assist you better. We cannot process incomplete forms. Thank you.
If you do not desire to fill out an online form you may print the Grant Request Form, complete it and mail it to us. Click here z

Please remember applicants must be former or current RHI patients

Today's date:

Name of patient requesting grant:

Name of person completing application:

Your relationship to patient:

Address:

City:

State:

Zip Code:

Telephone:

EXT:

E-mail:

Retype your e-mail:

Is the person with spinal cord injury a former or current patient of the Rehabilitation Hospital of Indiana?
Yes No
(If you checked 'No' above, please stop here. You do not qualify at this time if you are not a former or current patient at RHI)

Type of spinal cord injury:

Date of spinal cord injury:

Current therapy status:

Current occupation/work or school status:

Community activities you are involved in:

Current family situation:

Type of Insurance, if any:

Please describe your specific grant request:

Amount of grant request:
(Amount is required for grant application to be considered)

Please explain the specific needs this grant will meet:

Once you submit the form, you will receive a thank you page with the information you submitted to us, as well as a confirmation e-mail.