Empowerment Grant Application
The Empowerment Fund provides resources and inspiration to those who suffer a life-altering injury. These include spinal cord injuries, traumatic brain injuries, amputation or other mobility-limiting injuries that occurred in an individual's lifetime. The resources and inspiration that High Fives provides comes in the form of Board-approved grant funding, paid to service providers in specific funding categories: living expenses, insurance, health, travel, adaptive equipment, winter equipment, and High Fives' healing network.
Email address
Name
First and last name
Your answer
Name of person filling out application (if different from above)
Your answer
Date of Birth
MM
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DD
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YYYY
Address Line 1
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Address Line 2
Your answer
City
Your answer
State
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Zip Code
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Phone number
Please enter your number in the format ###-###-####
Your answer
Sex
Date of Injury
MM
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DD
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YYYY
T-Shirt Size
How did you hear about High Fives and the Empowerment Grant Program?
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