Grants

Sister-Bear, a tax-exempt non-profit foundation, is dedicated to the following mission: Sister-Bear Foundation’s mission is to provide access to adaptive fitness and wellness resources for mobility-impaired adults recovering from neurological accident or illness to improve their health, functionality, independence and quality of life.

Instructions for Financial Assistance Application:

To apply for financial assistance from the Sister-Bear Foundation, please complete and submit the application along with the required documents. Applications for Grant Funds are reviewed by the Sister-Bear Foundation Grants Committee on a quarterly basis. Grant funds are awarded based on availability of funds and at the sole discretion of the Sister-Bear Grants Committee and Sister-Bear Board of Directors. All applicants will be contacted following review of their application.

Eligibility:

Applicants must be 18 years and older.
Applicants must be diagnosed with a spinal cord illness/injury or another neurological accident or illness and are mobility impaired.
Applicants must reside in the top 26 counties of the Texas Panhandle or the surrounding four state area (Oklahoma, New Mexico, Kansas, Colorado).
All sections of the application must be completed, and all accompanying documents must be submitted prior to the Board reviewing the request.
Assistance may be requested one time during a fiscal quarter. Each request for assistance requires a new application submission.
Applicants must have financial need and may be asked to provide supporting financial documentation such as receipts, federal tax returns, SSI Benefits verification letters, etc.

Details:

Grants are paid to the applicant directly.
Grants are canceled if not used within one year.

The following are expenses considered for, but not limited to:

Wheelchairs	Bath / Shower Chair
Wheelchair Accessory or Modification (i.e.: SmartDrive)	Wheelchair Lifts
Vehicle Modifications (i.e.: hand controls, lifts)	Driver Evaluations & Training
Specialty Beds & Mattresses	FES Equipment
Home Medical Supplies (i.e.: catheters, adult diapers, mattress pads)	Patient Lifts
Home Modifications (i.e.: ramps, bathroom, hallway, etc.)	Prescription Medications
Therapeutic, Medical and Rehabilitation Services (i.e.: Voice therapy, Occupation, Physical, Aquatic, Equine, Massage, Rolfing, Acupuncture, etc.)	Travel Expenses incurred to travel to Therapeutic, Medical and Rehabilitation Services (i.e.: gas, hotel, food, etc.)
Service Animals (i.e.: Service animal, training)	Support Groups for Caregivers
Walker/Cane	Counseling / Mental Health Therapy

Expenses Not covered by this Grant are, but not limited to, the following:

Computer	Cell Phone
Living Expenses (i.e.: Rent, Utilities, etc.)	Mileage

Required Documents:

The application must be accompanied by a signed letter from applicant’s treating physician on that physician’s letterhead stating the applicant’s full name, date of birth and diagnosis.
Provide documentation showing denial from insurance company (if applicable).
Receipt(s) for expenses incurred within the last 3 months (if applicable).
Documentation of expected expenses related to the list above.

Please contact Sister-Bear Grants Committee Chair, Tracey Kilburn, at grants@sister-bear.com with questions concerning the application process.

If you would prefer to print and send the paper form, please click the button below for the printable PDF form.

Download PDF Form

Date of Application

Name:

Date of Birth

Name and relationship of person completing the application

Address

Street Address City State / Province / Region ZIP / Postal Code

Email Address

Phone

Medical Diagnosis / Nature of Disability

Indicate type of Request

Equipment

Travel Expenses

Therapy/Treatment

Other

(More than one type of request can be selected. Fill in the sections below related to your request.)

Equipment needed and cost

Travel expenses requested

(List the facility, duration and program, etc.)

Alternative treatment requested

(Include provider name, type of treatment, cost and duration.)

Other expenses requested

(Include quotes, receipts, denial from insurance company.)

Please provide a brief description of the applicant’s situation and the benefits the requested will provide. Please indicate the family’s ability and willingness to participate financially in the purchase if only partial funds can be granted.

Share how your injury or illness has changed your ability to work, socialize with friends and family and live an independent life.

Describe your physical abilities you lost as a result of your illness or injury. What mobility do you have now?

Please explain whether you have tried to obtain coverage for this request through insurance.

Have you received compensation for your injury?

Have you applied for grants from anyone else? If so, who and what is the status?

The application must be accompanied by a signed letter from applicant’s treating physician on that physician’s letterhead stating the applicant’s full name, date of birth and diagnosis(Required)

Max. file size: 24 MB.

Provide documentation showing denial from insurance company (if applicable).

Max. file size: 24 MB.

Receipt(s) for expenses incurred within the last 3 months (if applicable).

Max. file size: 24 MB.

Documentation of expected expenses related to the list above.

Max. file size: 24 MB.

LIABILITY RELEASE, DISCLAIMER & AUTHORIZATION TO USE NAME & LIKENESS

Liability Release:

In consideration of the receipt of grant awarded by Sister-Bear Foundation,

(the Recipient thereof), him/herself or through his/her legal guardian, hereby releases and forever discharges Sister-Bear Foundation, its officers, directors, employees, agents, affiliates and volunteers (hereafter collectively referred to as “Sister-Bear”) from and against any and all claims, of any type, which arise from or are related to:

Any alleged malfunction of or defect in the enabling equipment;
Any allegation that the enabling equipment was not appropriate or suitable for the Recipient;
Any other matter, of any type, related, in any way, to the Recipient’s receipt or use of the enabling equipment.
Any therapy / treatment complications or undesirable results
Any allegation that the therapy / treatment was not what was expected
Any other matter, of any type, related, in any way, to the recipient’s participation in travel or therapy/treatment.
Any matter, of any type, related, in any way, to any modifications made to the Recipient’s property that was not what was expected.

Name

Date

I stipulate that the information included in this application is true to the best of my knowledge. Further, I understand that the presence of inaccurate information in this application could result in the need for the re-evaluation of this application on the part of Sister-Bear.

Name

Date

Disclaimer:

Part of the mission of Sister-Bear is to provide funding to help purchase specialized therapy devices and mobility equipment to those suffering from spinal cord illness or injury or other neurological illnesses or injuries. Sister-Bear does not provide equipment, and as such, disclaims any and all liability for property damage and/or bodily injury resulting from the use of the equipment acquired with Sister-Bear funds. Sister-Bear disclaims any and all warranties with regard to the equipment acquired with Sister-Bear funds, including the warranty of merchantability and fitness for a particular purpose. Sister-Bear is merely a funding source. Sister-Bear is in no way responsible for reclaiming, disposing of, maintaining or repairing equipment. It is the sole responsibility of the Recipient to maintain, repair and/or dispose of the equipment. Any other costs that may be associated with the equipment such as installation, delivery, labor, disposal, etc. that are not explicitly stated on the application are the sole responsibility of the Recipient. All installations of ramps, lifts, stair glides, electrical supplies, etc. must be in compliance with applicable building codes. Sister-Bear is in no way responsible for ensuring compliance with any and all ordinances, codes and laws.

Before disbursement of any funds to purchase equipment, the Recipient must have this form signed, witnessed by a non-family member and returned to Sister-Bear.

I have read and fully understand and agree with the above Disclaimer.

Untitled

Check to agree

Applicant’s Initials

I have read and fully understand and agree with the above Disclaimer.

Untitled

Check to agree

First Legal Guardian’s Initials

am the Legal Guardian of

Untitled

Check to agree

Second Legal Guardian's Initials

am the Legal Guardian of

This document has been witnessed by

on this date

Authorization to Use Name and Likeness

The Recipient and his/her legal guardian hereby acknowledge and agree that acceptance of a grant from Sister-Bear Foundation may result in publicity. The Recipient and his/her legal guardian hereby irrevocably authorize Sister-Bear:

To publicize and use the Recipient’s likeness, voice and features, with or without his/her name, for any publication, promotion, trade or business use, or any other purpose.
To photograph, videotape, film and record each Recipient in any manner Sister-Bear Foundation chooses
To copyright, convey or otherwise distribute no or in the future, any such material involving the Recipient, his/her legal guardian and that said material may be distributed to anyone, for any purpose, including the general public, magazines, newspapers,television, radio stations
To publicize, now or in the future, the name of the Recipient including information regarding his/her physical condition and details regarding the equipment,therapy/treatment or services received from Sister-Bear Foundation.
The Recipient and his/her legal guardian agree that it is not necessary for Sister-Bear Foundation or anyone else to contact them prior to releasing any information authorized by this document. The Recipient and his/her legal guardian hereby releases Sister-Bear Foundation from and against any and all claims, of any type, which arise from or are related to Sister-Bear Foundation’s use, distribution or disclosure of any photographs,films, videotapes, electronic recording or other information regarding the Recipient and the award from Sister-Bear Foundation.

Applicant Name

Date

Legal Guardian

(Signature is required of all legal guardians.)

Date

ADDITIONAL INFORMATION

How did you find out about Sister-Bear Foundation?

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