SpecialKidsFund.org - Wheelchair van request

If you are in need of a handicapped adapted vehicle, please enter the following information. Please make sure to scroll down to fill in all of the necessary information

How did you hear about us?

Closest metropolitan area to you (large city):
City State abbreviation

First Name

Last Name

Address

City

State

Zip

Phone Number

Vehicle needed for

Type of Vehicle

Type of Funding I Can access

Gender

M F

Age of Disabled

Description of disability

Description of necessary vehicle type

Description of of funding I am eligible for: (VA, State, Loan, or other)

Description of income and financial situation

Sources of income

More on financial situation

Anything else you think we should know

Are you a member of a Veterans Organization?
Please enter full name of Organization/Chapter

I WOULD LIKE TO APPLY FOR MY OWN CROWDFUNDING FUNDRAISER IN SKF'S MagicMobility CAMPAIGN

Crowdfunding Campaign Info

Application is pending approval. We will contact you if approved.

Amount needed for your campaign, to enable you to adapt or purchase a wheelchair van: $5,000 $10,000 $15,000 $20,000 Other
You have a case worker and/or physician who can verify the need for your campaign
Do you currently participate on internet social media websites? Y N
Please check and enter the information:
Facebook	# Followers	Your Facebook Page: https://www.facebook.com/
Twitter	# Followers	Your Twitter Feed: https://twitter.com/
Instagram	# Followers	Your Instagram Page: https://www.instagram.com/
Google Plus	# Followers	Your Google Plus Page: https://plus.google.com/+
Other:	LINK/URL for Your Page
You will provide us with:
Pictures
Video
You agree to: Speak directly with friends and family to:
Donate	How Many?
Share Campaign with their social network	How Many?
Contact local media about your campaign (TV, radio, etc.)
In a few short sentences, please describe why you require a mobility van and how you believe a van will improve your quality of life.
We are only able to post a limited number of applicants campaigns (10-25) at any one time. Explain how and why you think that you will be able to help make a successful campaign:
Accept Terms (I agree to co-operate in providing materials and doing all I can to promote my campaign. If the goal is not reached to enable the purchase of a van, paid to the dealer, within 12 months, then you can use the donations towards; Handicapped accessible bathroom, Stair lift, Stationary or portable ramp or Recreational expenses (entrance fee for family trip to amusement park). In no case, can donations be taken as cash. Special Kids Fund, deducts a 10% management expense for credit card charges, posting fees, etc.)

Security Check:

Click on the "Submit" button below to submit your request.

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