Application Form

  • Contact information

  • Patient information

  • Diagnosis confirmation from your physician will be required if selected.
  • Example: 3 feet and 6 inches
    Answering "Yes," will not automatically disqualify your application. That said preference is given to those applicants who do not currently have a manual wheelchair.
  • If you have any more information you would like to add to your application, you can do so here. If you have any questions, please email Jeff Horton at
  • Demographic information (optional, not used in decision process)