How did you hear about us?
Closest metropolitan area to you (large city):
City
State abbreviation
First Name
Last Name
Email
Address
City
State
Zip
Phone Number
Vehicle needed for
Please choose one...
Disabled child
Disabled adult
Disabled Police or Public Safety Officer
Disabled VET
VET with a disabled family member
Type of Vehicle
Please choose one...
Wheelchair van
Adapted for scooter
Non-adapted vehicle for disabled person who can transfer
Van with hand controls for disabled driver
Type of Funding I Can access
Please choose one...
None
Veterans
State
Loan
Other
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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