Name *

Mailing Address (Home Address) *

City, State, Zip *

Phone number *

Have you previously received a GUSU Adaptive Fitness Scholarship? *

Have you previously applied for a GUSU Adaptive Fitness Scholarship?

Date & Level of Spinal Cord Injury *

How did you hear about GUSU and the GUSU Adaptive Fitness Scholarship? *

Have you participated in an Adaptive Fitness Program previously or currently? If so, where? *

Name of Adaptive Fitness Program you will participate in and anticipated start date? *

How would receiving a GUSU Adaptive Fitness scholarship impact your life? *

Is there anything else you would like the GUSU board to know in reviewing your application? *

If selected are you willing to have your name and/or picture used on GUSU social media and provide a short testimonial for future GUSU promotional purposes? (Answer will not effect applicants eligibility or chances of being selected as scholarship recipient) *