2025 Scholarship Application

(Note: All information contained in this application will be kept confidential.)

Applicant Information

Name:

Street Address:

County of residence:(For example: Pitkin County/Eagle County/Garfield County)

County of work:

Contact Phone:

Email Address:

Date of Birth:

Driver’s License ID:

OR Other Government Issued ID:

Name of person filling out application:

Relationship to Applicant:

Diagnosis

Medical neurological diagnosis/injury:

Date of diagnosis/injury?

Cause of injury?

Physician / Rehabilitation Information

Primary Care Physician:

Address (office):

Contact number:

Primary Rehabilitation Therapist:

Address (clinic):

Contact number:

Financial Information

Number of dependents:

Annual Income: $

Source(s) of Income:

Please note that Bridging Bionics Foundation may request proof of income in the form of a tax return or bank statement. All information is confidential and is used only for the purpose of evaluating your request.

Healthcare

The following information is helpful for us to know, as the Bridging Bionics Foundation (BBF) program is a charitably funded initiative. We recognize that Medicare/Medicaid and some insurance companies currently do not reimburse for Galileo Training Systems or exoskeleton therapy.

1. Medicare is a federal program that provides health coverage if you are 65 or older or have a severe disability, no matter your income.
2. Medicaid is a state and federal program that provides health coverage if you have a very low income.

If you are eligible for both Medicare and Medicaid (dual eligible), you can have both.

Services Needed

Duration:

How will this sponsorship help you?

Briefly describe your immediate needs or concerns:

Is there anything else you would like to tell us about yourself?

Bridging Bionics Foundation believes in the expression of “paying it forward”. How have you, or how do you, plan to pay it forward?

Waiver and Truth Statement

“Any decision by Bridging Bionics Foundation (BBF) as to: a) whether or not a sponsorship is to be awarded and b) if awarded, in what amount and the terms and conditions attaching thereto, shall be made in the sole and absolute discretion of BBF. Sponsored applicants in the program will agree to adhere to a 24-hour cancellation policy for scheduled sessions. If a session is cancelled by the sponsored applicant within 24-hrs and is not considered an emergency, the sponsored applicant agrees to pay for the actual cost of the session (which is $75/hr). By your submission of this sponsorship application to BBF, you agree to be bound by the decision of BBF and indemnify and hold BBF harmless from any and all claims, actions and/or causes of action arising directly or indirectly as a result of BBF’s decision.”

BBF uses sponsorship bios and related media (photos/videos) to assist in fundraising efforts to complete our mission. The statements and answers given in this sponsorship application are true and correct. I understand that misstatements in this sponsorship application could cause my application to be denied.

Applicant’s Name (please print):

If under the age of 18, please have parent or guardian sign this Request

Parent/Guardian Name (please print):