The Recovery Project

Contact Information: (Section 1 of 8)
Name:
Address:
City:
State:		Zip:
Home Phone:		Cell Phone:
Email:

Personal Information: (Section 2 of 8)
Date of Birth:	Sex:	Male Female
Height:	Weight:
Level of Spinal Cord Injury:
ASIA Level/Score (If Known):

Diagnosis: Complete Incomplete
Date of Injury:
How were you injured:

At what hospital were you treated?
Treating Physician:
Current Physician:
Date of Last Medical Exam:
Past Surgeries:

Medications:

Describe present support systems (family, caregivers, etc.):

Emergency Contact Information: (Section 3 of 8)
In case of emergency, please notify:
Name:		Relationship:
Home Phone:		Work Phone:

Ability Information: (Section 4 of 8)
Describe your physical abilities (Be as specific as possible, particularly with respect to your legs):
Upper Extremities:

Trunk (IE: Can you sit up?)

Lower Extremities:

Please list any physical problems or special considerations (IE: osteoporosis/osteopenia, knee instability, obesity, hypersensitivity, rods in back, other health issues):

Previous Rehabilitation (if any):

Date last attended:
Results:

Insurance and Resources Information: (Section 5 of 8)
Medical Insurance:
Physical Therapy Benefits:

Grant applications are considered for individuals that have no therapy benefits available from insurers (including Medicare) and are without personal resources to pay for therapy - please note the highlighted section from our mission statement:

While scientists, doctors and researchers around the world seek a cure for spinal cord and other neurological injuries, the reponsibility of high intensity rehabilitation therapists is to keep those of us with SCI/TBI healthy and fit until a cure is found, or in a lifetime of fitness.

Unfortunately, there are injured individuals without the healthcare benefits or private resources for ongoing therapy and exercise.

The mission of The Mary and Charles A. Parkhill Foundation for Spinal Cord Rehabilitation is to raise funds that will be granted to those individuals, in the form of scholarships, to obtain therapy services.

Please describe your specific circumstances related to the availability of resources to fund physical therapy:
Insurance:

Personal Resources (including Trust Information):

Can you pay any portion of the cost of therapy? Yes No
If yes, how much per month: $

Consideration Information: (Section 6 of 8)
Please tell us your goals and aspirations, what you hope to achieve from rehabilitation:

Why should you be considered for this grant:


Recommendations Information: (Section 7 of 8)
Please add two letters of recommendation.

Certify Information: (Section 8 of 8)

Full Name: Date:

If under 18 years of age, name and date of parent or guardian:

Full Name: Date:

Relationship:

In order to sign this application electronically, type the validation code you see below:
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By signing, I hereby certify all statements to be true. If found otherwise, I understand that all or portions of any grant can be forfeited.