Please answer the following questions so we can get to know you better!

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Did you suffer a life-altering injury while pursuing a dream in a winter sport? (*)



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Did you suffer a spinal-cord injury? (*)



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Did you suffer a Traumatic Brain Injury? (*)



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Did you suffer a life-altering injury and now have goals in winter sports? (*)



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Please Download The Following Documents BEFORE continuing on




Please verify that you have downloaded AND read all 4 documents above before continuing.





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Almost Finished!




Name (*)

Please Provide your name
Age (*)

Please enter your age
Date Of Birth (xx/xx/xxxx) (*)

Please enter your age
Sex (*)



Please let us know if you are a man or woman
Birthplace (*)

Where were you born
E-mail (*)

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Phone Number (*)

Please provide your phone number
Address (*)

Please provide your address
Current City

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T Shirt Size

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Date Of Injury (xx/xx/xxxx)

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Give a description of the extent of your injury/injuries and how it/they occurred.: (*)

Please describe your injury
What is your recovery goal? (*)

Please describe your recovery goal
How can High Fives help you reach your goal and follow through with your plan? (*)

Please describe how High Fives can be of assistance
Hospital (*)

What Hospital
Current Mountain

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How did you hear about High Fives and our athlete scholarship program?:

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Adjusted Gross Income (reported on previous year's tax return) (*)

Please provide your previous year's income
Briefly Explain your immediate needs (*)

Please provide us with a brief explanation of needs
Are you a paid profesional in your sport (*)



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How Many Days Were You In The ICU? (*)

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How Many Days Were You In In-Patient Rehab? (if applicable)

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Race (just for statistical purposes) (*)

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Spinal Cord Injury Level (if applicable)

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Complete/Incomplete Injury (if applicable)

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Name of Person Filling out application (*)

Please type your full name.
Waiver and Truth Statement - "The statements and answers given in this grant application are true and correct. I understand that misstatements in this grant application could cause my application to be denied." (*)

You MUST verify your statements in this application are true
This is for your security
This is for your security

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If you have any difficulty filling out this form, please feel free to contact roy @ highfivesfooundation.org

 

             

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