Application Form

1. Please complete the following application (all pages) in it’s entirety.

2. Provide the following:
- Copies of the requested applicant report card
- Essay requested from the Academic Information section in the application
- Signed copy of One Chair at a Time Requirements, Rules, and Regulations
Application Date*
MM slash DD slash YYYY
How did you hear about One Chair at a Time?*
Recipient Information
Name
First Last
Date*
MM slash DD slash YYYY
Age*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Gender
- Male
- Female
Primary Phone*
Secondary Phone
Email*

example@example.com
Height*
Weight*
Dominate Hand*
Disability*

Parent/Guardian Information
Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Primary Phone*
Secondary Phone
Email*

example@example.com
Relationship to Recipient*
Additional Information
Primary Guardian Occupation
Employer
Currently Employed?
- Yes
- No
Secondary Guardian Occupation
Employer
Currently Employed?
- Yes
- No

Do you currently own a sports wheelchair?
- Yes
- No
What type of sports wheelchair(s) would you like to receive?*
Have you ever participated in adaptive sports?
- Yes
- No
If yes, please describe
If I outgrow my sports chair, I agree to “recycle” for use by another athlete
- Yes
- No
Academic Information
Current GPA / Grades from most current report card*
Extracurricular Activities

Financial Assessment of Parent/ Guardian
Monthly Household Income:*

(Wages, SSI, SSDI, etc.)
Liabilities (Long Term Expenses)*

(Mortgage, Medical Bills, Credit Cards,etc.)
Assets (Current Balance)*

(Savings, Checking Accounts, Investments, etc.)
Marital Status*
- Single
- Married
- Divorced
- Widowed
# of Dependents*
List Ages*
Additional financial verification may be required at a later time to determine eligibility of the applicant.
The above information is complete at correct to the best of my knowledge. One Chair at a Time will not be held responsible for any injury, harm, or damage to oneself, others or property during the recipient’s use of this chair.
Applicant Signature*
Parent/Guardian Signature*
Photo and News Release:
I authorize One Chair at a Time to use photographs and information about my child for promotional and news release purposes.
Signature
Date*
MM slash DD slash YYYY

Requirements, Rules, and Regulations
The athlete will submit a written application to be considered to receive a sport wheelchair from One
Chair at a Time, “OCAAT”.

Must be minimum age of 7, and maximum age of 19.

The sport wheel chair can be taken back by OCAAT if it is not being properly or regularly used.

The sport wheelchair must be returned in the same working order as when it was received.

The athlete must compete in a sanctioned sporting event in the wheelchair with in six months of receiving it and provide proof of competing.
OCAAT will not be held responsible for broken or misused equipment. All maintenance of chairs will be the responsibility of the individual receiving the chair.

The Athlete must be physically able to transfer in and out of a sport wheelchair with minimal assistance.

The Athlete must provide a physicians release stating that he or she is physically, mentally and emotionally able to compete in competitive sports.

The Athlete must attend at least one wheelchair clinic or educational opportunity put on by OCAAT to help the athlete learn to use the sport wheelchair properly and safely.

OCAAT will not provide any transportation or compensation to attend or travel to an educational clinic or sporting event.

If the Athlete is regularly using the sport wheelchair and out grows it, OCAAT will take the Sport Wheelchair back and replace with a properly fitting new Sport Wheelchair.

Assessments for sport wheelchairs to be completed by licensed physical therapists with the assistance of licensed physical therapist assistants provided by OCAAT.

By signing below I certify that I have read, understand, and comply to agree with all rules and regulations of
One Chair at a Time listed above.
Applicant Signature*
Parent/Guardian Signature*
Date Filled*
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

Recipient Information

Parent/Guardian Information

Academic Information

Financial Assessment of Parent/ Guardian

Requirements, Rules, and Regulations

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