We Periodically Giveaway a MagSHOCK® to Those People in Need

Grant Application

Since we are in wheelchairs ourselves, we understand the difficulties each of us may face while doing life on wheels. We also understand that times are hard for so many of us right now. Which is why we felt we needed to offer our Grant Program. This is our way to give when we can to those in need. We ask that you fill out the questionnaire below and let us know more about yourself. Each question tells us more about you and helps our staff immensely as we sort through all of the applications we receive.

Name: (required)*
First Last
Address: (required)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone: (required)*
Email: (required)*
Enter Email Confirm Email
Facebook URL (required)*

If you have a Facebook page please provide the direct link to your page.
Linkedin URL

If you have a Linkedin page please provide the direct link to your page.
Instagram URL

If you have a Instagram page please provide the direct link to your page.
FOLD & GO COMMUNICATION:
Have You Previous Contacted Us About Our Products? (required)*
- Yes
- No
Do You Have Medical Insurance? (required)*
- Yes
- No
Are you on Medicare/Medicaid/Disability/VA insurance? (required)*
- Yes
- No
MEDICAL INFORMATION:
Primary Diagnosis: (required)*
ICD CODES: (required)*
Approximate Diagnosis Date: (required)*
MM slash DD slash YYYY
Date of Birth: (required)*
MM slash DD slash YYYY
GRANT APPLICATION QUESTIONAIRE:
Tell us about yourself. What's your story? (required)*
What motivates you? (required)*
What are your pet peeves? (required)*
What would you like to change about yourself? (required)*
What is the greatest obstacle you’re facing right now? (required)*
What medical devices are you currently using or have used in the past? (required)*
What is the question people ask you most often? (required)*
What is your greatest achievement? (required)*
What is your greatest failure? (required)*
What would you do if you woke up and found an elephant in your backyard? (required)*
If something in your house breaks, what is the first thing you do? (required)*
What was the happiest period of your life? (required)*
Tell us a Joke. Do not forget to tell us the Punchline too. (required)*
Tell us something you’ve taught yourself in the last six months. What resources did you use? (required)*
We receive hundreds of grant applications, why should we choose you over other applications? (required)*
SUPPORTING FINANCIAL DOCUMENTS: (required)*
Please upload a copy of Last Year's Tax Return or a Social Security Benefits Letter/Statement. Please BLACK OUT your Social Security Number, and any Bank Routing information.
Accepted file types: pdf, jpg, gif, png, Max. file size: 300 MB.
CAPTCHA

Grant Program

We Periodically Giveaway a MagSHOCK® to Those People in Need

Grant Application

FOLD & GO COMMUNICATION:

MEDICAL INFORMATION:

GRANT APPLICATION QUESTIONAIRE:

Take an Additional $300 OFF ALL Wheelchair Models for Military/First Responders