Madison West Kiwanis Foundation Scholarship Application
This scholarship includes round trip airfare from Madison to Durango, Colorado, five nights lodging in a Durango hotel, meals, four days of ski instruction, lift tickets, local transportation, and all necessary ski equipment. Since we seek to accommodate individuals with a wide range of physical disabilities, selection is based on numerous factors (mix of disability types in a traveling group, available funding, capacity of the ski school, etc.) It is therefore important that you complete this application as honestly accurately and completely as possible. The questions are not meant to disqualify applicants; they are designed to give the Foundation and the ski school as much information as possible to assure a successful ski experience.
First Name *
Last Name *
Mailing Address *
City *
State *
Zip Code *
Email Address *
Cell Phone *
Birth Date *
MM
/
DD
/
YYYY
Occupation
Height *
Weight *
Shoe Size *
Emergency Contact Name *
Emergency Contact Relationship *
Emergency Contact Cell Phone Number *
Disability (Please be very specific) *
Secondary Disabilities (diabetes, scoliosis, learning, etc.)
Cause of Disability
Date of Injury/Diagnosis
MM
/
DD
/
YYYY
Do you have a spinal cord injury?
Clear selection
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy