ALL-TERRIAN WHEELCHAIR APPLICATION

Payment-free Wheelchair Donation

In Partnership with U.S. Bank

APPLICATION INFORMATION

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Cellphone *

Other Phone

How did you hear about this program? *

Other - How did you hear about this program?

Email *

DISCLOSURES

Are you related to or do you have business ties to any VAREP staff, members of their immediate families, VAREP Board members, members of their immediate families, and such individual’s business associates? *

Yes

If Yes, Name

Relationship

ALL-TERRAIN WHEELCHAIR NEEDS ASSESSMENT

Do you currently have a wheelchair or mobility device? *

Yes

If yes: What type? (Wheelchair or mobility device)

Other (Wheelchair or mobility device)

Is your current mobility device adequate for outdoor, rough terrain use? *

Yes

What difficulties do you experience with your current device? Check all that apply

How often do you expect to use an ATW? *

Daily

Weekly

Monthly

Seasonally / Occasionally

Check all that apply

What are the primary purposes for using an ATW? *Check all that apply

Please describe any specific physical needs or preferences related to seating, controls, supports, or accessories:

MILITARY/ VETERAN DETAILS

Are you service-connected rated by the VA?

Yes

If Yes, what is your disability rating?

Please describe the injuries your sustained in service. *

How will this assistance impact you rehabilitation or help improve your life. *

Branch of Service/Hero Affiliation *

Discharge Status *

Pay Grade

MOS/Rate/Job Title

Command

Years of service *

Dates of deployments/When will you deploy/ Location of deployments

Do you have a service animal, if so please list *

Yes

Please, describe service animal:

FAMILY

Family Status *

Married

Single

Divorced

Widowed

Household size *

Family Members

Member 1
Member 2
Member 3
Member 4
Member 5

Add Name, Age and Relation to Applicant

REFERENCES- LIST 3 REFERENCES

Reference 1 Name *

First Name
Last Name
Phone Number (Reference 1 )
Email Address

Reference 2 Name *

First Name
Last Name
Phone Number (Reference 2)
Email Address

Reference 3 Name *

First Name
Last Name
Phone Number (Reference 3)
Email Address

UPLOADS

Government Issued ID *

PDF, PNG, JPEG, JPG or GIF Accepted file types: jpg, gif, png, pdf.

DD214 *

PDF, PNG, JPEG, JPG or GIF Accepted file types: jpg, gif, png, pdf.

VA Disability Letter - If Applicable

PDF, PNG, JPEG, JPG or GIF Accepted file types: jpg, gif, png, pdf.

Pictures in Uniform- veteran should be easily recognized with face clearly visible. *

Up to 5 documents

PDF, PNG, JPEG, JPG or GIF ( max 5 Files )Accepted file types: jpg, gif, png, pdf. 3 minimum, up to 5 documents.

Pictures of veteran NOT uniform. You with your spouse/partner/family are encouraged. *

Up to 5 documents

PDF, PNG, JPEG, JPG or GIF ( max 5 Files )Accepted file types: jpg, gif, png, pdf. 3 minimum, up to 5 documents.

Have you ever been convicted of, or entered a plea of guilty, guilty but mentally ill or nolo contendere to a gross misdemeanor and/or felony? *

Yes

If you answered YES, you are REQUIRED to attached a written explanation and the final court issued disposition document OR a brief written explanation of the discipline imposed by any real estate regulatory agency or commission on an attached sheet.

PDF, PNG, GIF, JPEG or JPG Accepted file types: jpg, gif, png, pdf.

APPLICANT ACKNOWLEDGEMENTS

(Please check each box to confirm your understanding and agreement.)

ACKNOWLEDGEMENTS *

I certify that all information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that providing false or misleading information may result in disqualification from the program

I understand that selection is not guaranteed and that all applicants are subject to a vetting process conducted by VETCares per U.S. Bank program wheelchair donation guidelines.

I agree to fully cooperate throughout the vetting and selection process, including providing references, a short biography, photographs, and any additional documentation reasonably requested.

I agree to participate in required virtual meetings or interviews (e.g., Zoom, Microsoft Teams) as part of the review and selection process.

If selected, I agree to comply with all pre- and post-donation program requirements established by VETCares and U.S. Bank’s wheelchair donation guidelines.

I understand that the donated wheelchair is intended to support my personal transportation and stability. I agree that I will not sell, transfer, or otherwise dispose of the vehicle for a period of twenty-four (24) months following the date of donation, except with written permission from VETCares.

I release VETCares and its partners/ affiliates from liability related to program participation.

TALENT & MEDIA RELEASE *

By submitting this application, I grant VETCares and U.S. Bank permission to use my name, likeness, image, voice, photographs, and story for program-related communications, including websites, social media, reports, and promotional materials, without compensation. I understand this may include written, photographic, and video content created during the application, vetting, and donation process.

Tax & Legal Disclaimer *

I understand that I am responsible for any personal tax or legal obligations associated with receiving a donated wheelchair.

Background Check

I understand and consent to VETCares conducting a local, state, and federal background check as part of the vetting and selection process. I acknowledge that eligibility may be affected by the results of these checks.

Signature (Use your mouse to sign) *

Clear

Date *