Grant Application | Thomas E Smith Foundation

Contact Information

Applicant's Name(Required)

First Last

Applicant's Email Address(Required)

If different from your email

Enter Email Confirm Email

Your Name

Must be completed if you are applying on behalf of someone other than yourself

First Last

Describe your relationship to the applicant

Your Email Address

Enter Email Confirm Email

Preferred Contact Number(Required)

Please share the best phone # for us to reach you

Applicant's Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

More About You

Please answer the following questions to the best of your ability

Date of Injury or Diagnosis(Required)

Please select from one of the options below

Level of Injury

Please select the highest level of spinal cord vertebra injured (if applicable)

Please describe what caused your injury or diagnosis(Required)

Are you working with a social worker or case manager?(Required)

If you answered "Yes" on the last question, please complete this section:

Name

First Last

Their Email

Their Phone Number

In a brief statement, tell us about yourself and some of your interests:(Required)

How has your injury or diagnosis impacted your ability to work, socialize with friends and family, and live an independent life?(Required)

Have you received a settlement or compensation as a result of your injury?*(Required)

Describe your sources of financial support and typical expenses (SSI, Employment, Other Grants, etc.)(Required)

Please note: Grant recipients may be asked to provide supporting documentation such as tax returns or letters of determination

Describe additional resources, means, or methods you have pursued or will pursue to fund your request:(Required)

What are you applying for?(Required)

Grant amount requested(Required)

Please note: Maximum award is $25,000

Approximate total cost of item or project(Required)

Have you been in contact with any vendors or service providers for a quote or estimate?(Required)

If you answered "Yes" on the last question, please complete this section:

Company Name

Website

Contact Information

First Last

Email

Phone Number

Address

Street Address Address Line 2 City State ZIP Code

Price Quoted

Please upload a vendor-provided estimate, quote, or proposal here

Drop files here or

Max. file size: 50 MB, Max. files: 3.

Is there anything else you would like to tell us?

Signature:(Required)

Your typed name indicates your signed consent

Today's Date(Required)

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Contact Information

More About You

If you answered "Yes" on the last question, please complete this section:

If you answered "Yes" on the last question, please complete this section:

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