Application for an Individual K
Grant
Eligibility:
Individual K Grants are awarded
to persons living with a spinal cord disability or their immediate
family or caregiver(s). The Kevin Kitchnefsky Foundation for Spinal
Cord Research does not award cash grants. When an Individual K Grant is
awarded, the Foundation pays the monies directly to the organization or
individual providing the product or service that you are requesting.
Your application must be accompanied by three written estimates,
submitted by three different firms, that include an estimate, terms of
payment, an outline of work/product that will be provided and a
projected date of completion/delivery.
Goal: To substantially improve the quality of life for the people
affected. Instructions:
Print and fill out this application completely. Use additional paper for
the essays, then attach them to the application and mail to:
Kevin Kitchnefsky
The Kevin Kitchnefsky
Foundation for Spinal Cord Research
109 German Hill Road
Tunkhannock, PA 18640
Privacy:
Please note that your information will be kept private and not sold or
shared with any other organization. You may, from time to time, be
contacted by The Kevin Kitchnefsky
Foundation for Spinal Cord Research regarding events, volunteer
opportunities and other Foundation activities.
Questions may be directed to Kevin or Yvonne at (570) 836-1240.
Step One: Submit your Application for review.
Step Two: We will contact you to set up a personal interview with
a designated liaison.
Step Three: Our Board of Directors will review your application
and the report from our liaison's personal visit with you.
Step Four: Our Board of Directors will select the recipients. All
decisions are final.
Required Information:
Name of Injured
Person_______________________________________________________
Date of Birth_____________________ Social Security
#___________________________
Mailing
Address______________________________________________________________
City_______________________________ State______________
Zip_________________
Telephone (day)_____________________________________________________
Telephone (evening)__________________________________________________
Email__________________________________________________________ Fax_____________________________________________________
Name of Primary Caregiver (or person who would speak with us on
your behalf)
____________________________________________________________________
Telephone (day)_____________________________________________________
Telephone (evening)__________________________________________________
Email__________________________________________________________
Fax_____________________________________________________
If you are requesting financial assistance from other organizations,
please list them:
__________________________________________________________________________
__________________________________________________________________________
Amount Requested: $_____________
(use the estimates to decide on an amount)
Is this request time-sensitive? (circle one) YES
NO
If so,
explain________________________________________________________________
__________________________________________________________________________
Essay Section - Part 1:
In 300 words or less, please tell us about your situation.
Essay Section - Part 2:
In 300 words or less, tell us how a K Grant would substantially
contribute to your quality of life.
Financial Section:
Please attach a copy of your most recent federal tax return.
Thank you for your interest in receiving a K Grant!
Signature of person filling out this
request_____________________________
Date_____________ |