Application | HandiCapable Foundation

Date of Application

Section 1: Personal Details

Name

First

Last

Phone

Email

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Emergency Contact:

Name

First

Last

Relationship:

Phone

Section 2: Disability & Medical Information

(Optional but helpful for prioritization)

1. Nature of disability or injury:

Amputation
Paralysis
Chronic Illness
Other

2. Date of injury/ disability onset:

3. Do you use mobility aids?

Wheelchair
Prosthetics
Cane/ Walker
Other

Section 3: Home & Vehicle Accessibility Needs

1. Type of Support Requested:

Home modifications (e.g., ramps, bathroom adaptations)
Vehicle adaptations (e.g., hand controls, lifts)
Other

2. Specific Modifications Needed:

(Example: “Widening doorways for wheelchair access” or “Installing a stairlift”)

3. Urgency:

Immediate safety risk (e.g., cannot exit home safely)
High need (e.g., unable to perform daily tasks)
Moderate need (e.g., improves quality of life)

4. Current Barriers:

What challenges do you face daily due to lack of accessibility?

Section 4: Financial & Resource Status

1. Annual Household Income:

Below R10k
R10k–R15k
R15k–R25k
Above R25k

2. Have you applied for other assistance?

Medicaid/Medicare
VA Benefits
Local Grants
None

If denied, please attach denial letters.

Click or drag a file to this area to upload.

3. Are you able to contribute to the cost?

Yes
No

Amount

4. Attach Documentation (if available/optional):

Click or drag a file to this area to upload.

Section 5: Impact & Consent

1. How would these modifications improve your independence?

2. Consent Agreements:

I consent to a home/ vehicle assessment by Handicapable Foundation.
I allow my story/ photos to be shared (anonymously) for fundraising.

Section 6: Submission & Follow-Up

Signature

Clear Signature

Date

What Happens Next?

- Applications are reviewed, expect response within a the coming weeks. - Priority is given to urgent safety needs and those with limited resources. - If we cannot assist now, we’ll keep your application on file.

Thank you for trusting us with your journey.

Nico van Niekerk, Ambassador | Handicapable Foundation

How did you hear about us? (Optional)

Social Media
Doctor
Friend

Would you like to volunteer with us? (Optional)

Yes
No

Application for Adaptive Independence Support