The Hartford Athlete Adaptive Equipment Grant Application

Save & Continue Later

The "Save & Continue Later" function can be found at the bottom of this report form. If selected, a pop-up notice will provide a unique URL which will allow you to access the form at a later time. The URL will also be sent via email to the primary email address listed. Move United cannot access partially completed forms or the URLs associated with the forms. To avoid information being lost due to connectivity or browser issues, a recommendation is to copy and paste this application to a word document, fill out the responses in the word document and then cut and paste answers to this application form for submission.

Grantee Information

Who is completing this grant application?*

Athlete; I am completing the application for myself and I am a adult
Athlete; I am completing the application for myself and I am a minor
Athlete's Parent/Guardian
Athlete's Coach/Instructor

Who referred you this grant opportunity?*

This grant is currently by invitation only from a Member Organization, Competition Series event, Ski Spectacular, or The Hartford

An Upcoming Move United Event / Competition Series Event
A Move United Member Organization / Chapter
Other

Name of Move United Event / Competition Series Event*

If you will be attending multiple competitions, please indicate all you will be competing in under the list of adaptive sport events/competitions you plan on participating in

Texas Parasport Games in Partnership with The Hartford
Gateway Games in Partnership with The Hartford
Desert Challenge Games in Partnership with The Hartford
Great Lakes Games in Partnership with The Hartford
The Hartford Nationals
The Hartford Ski Spectacular

Other - Please specify who referred you and the organization they are with*

Please provide the name of the Move United Member Organization that invited athlete to apply for this grant opportunity*

I understand that athlete(s) selected will NOT be notified ahead of time, but will be surprised at an event hosted as part of a Member Organization, Competition Series, Ski Spectacular, or The Hartford activation.*

Yes, I understand and I will be present at the presentation/gifting moment

Athlete Name*

First Last

Athlete Address*

Address City State Zip Code

Phone*

Email*

Date of Birth*

This field is hidden when viewing the form

Gender*

I identify my gender as (select all that apply)*

My pronouns are*

She/Her/Hers
He/Him/His
They/Them/Theirs
Prefer to self-describe

Prefer to self-describe:

This field is hidden when viewing the form

I identify my ethnicity as*

Select all that apply

I identify my race/ethnicity as (select all that apply)*

Prefer to self-describe:

Disability Information (select all that apply)*

Option to provide Disability Specific Information

Parent/Guardian Name (for minors)

Required for athletes under the age of 18

Parent/Guardian Phone (for minors)

Required for athletes under the age of 18

Parent/Guardian Email

Required for athletes under the age of 18. Parent/Guardian for minors will be sent a copy of the application to this email.

School or University/College

If currently in school

Grade Level or Year

If currently in school

Are you a Veteran with a disability?*

Yes
No

Sport Information

When answering this section of questions, please focus your answers on the sport under which you are applying for.

What is your sport?*

Must be recreationally or competitively active in this sport. The grant currently does not include equipment for the following sports: Adaptive Shooting, Biathlon

Other - Sport

Number years participating and/or competing in selected sport*

Are you currently associated with Team USA / US Paralympics in this sport?*

Yes
No

Do you currently participate on a school sport team?

Yes
No

If yes, what sport(s)?

Do you currently participate on a team/training program outside your school?*

Yes
No

Primary Instructor/Coach Name*

Primary Instructor/Coach Email*

Primary Instructor/Coach Phone Number*

Athletic Goals: Short and long term goals*

Please be thorough and provide us with both your short AND long term athletic goals

List adaptive sports events/competitions you attended in the last 12 months AND plan on participating in the next 12 months*

Provide event name, dates, and locations

Adaptive Equipment Request

List the adaptive equipment you are requesting*

Provide as much detail as possible, including: current quote from vendor OR manufacturer, model, sizing specs, website link, and any additional pertinent information.

Equipment cost*

Grant request cannot exceed $5,000, including shipping. Excess or additional equipment cost for upgrades, enhancements, or modifications will be the grantee's responsibility.

Do you currently have a similar piece of equipment you are applying for?*

Yes
No

If yes, how or why this new piece of equipment will help you achieve your athletic goals?

Equipment Sizing Information

To assist with equipment orders and sizes, please provide the information, as appropriate for equipment you are requesting:

Height*

Head Circumference or Helmet Size (for helmets/hats)*

Weight*

Shoe Size

If your sport requires a shoe size, please list your size below (ex. skiing, snowboarding, etc)

T-Shirt Size*

Unisex sizing

Additional Information

General Information & Goals*

Provide any additional information you would like to share (i.e. education goals, community service, other sports you participate in, awards recognition, links to media, etc.)

Do you qualify for one or more of the following programs?*

Free School Lunch Program; Temporary Assistance for Needy Families; Aid for Dependent Children; Foster Care; Medicaid; Parent/Guardian Unemployment; Other similar Local, State, or Federal Programs

Yes
No
Prefer not to answer

Sharing your story can encourage others potential athletes and demonstrate the importance of adaptive sports and Elite team program. Are you willing to share your story online or with media?*

Yes
No

I would like to share my social media usernames:

Ex.) Instagram= @joesmith123

Attach additional material you would like to share.

Sport action photos or video clips. For video content, consider the following questions. Tell us about yourself: How did you get to where you are? What is your typical day like? What do you do for fun? Training: What is your routine? Have someone capture some footage of you training. If attending Ski Spec: Have you ever been? What has been your experience in the past? or What are you most looking forward to?

Drop files here or

Accepted file types: jpg, gif, png, pdf, mp4, Max. file size: 9 MB, Max. files: 4.

Submit

You should receive a confirmation notification to the email address submitted in your application. If you do NOT receive a confirmation, please contact Micaela Venus at mvenus@moveunitedsport.org to confirm your submission was received for review.