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 *
Your answer
Last Name *
Your answer
Mailing Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Email Address *
Your answer
Cell Phone *
Your answer
Birth Date *
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DD
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YYYY
Occupation
Your answer
Height *
Your answer
Weight *
Your answer
Shoe Size *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Relationship *
Your answer
Emergency Contact Cell Phone Number *
Your answer
Disability (Please be very specific) *
Your answer
Secondary Disabilities (diabetes, scoliosis, learning, etc.)
Your answer
Cause of Disability
Your answer
Date of Injury/Diagnosis
MM
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DD
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YYYY
Do you have a spinal cord injury?
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