USAofVA Ramp Project Form Submission Applicant's name:* First Last Applicant's phone number:*Applicant's email:* Applicant's date of birth:* MM slash DD slash YYYY Is the applicant a resident of Virginia?* Yes No Applicant's Address:* Street Address City State / Province / Region ZIP / Postal Code What are the last four digits of the applicant's SSN?* What is the applicant's living situation?* Own Rent Other If you chose "other" please explain or provide the applicant's landlord contact info.*Is the applicant a member of the United Spinal Association of Virginia?*If no, please go to www.unitedspinalva.org/membership and complete the FREE application before proceeding Yes No Is the applicant currently admitted to an inpatient rehab facility?* Yes No If yes, which facility?* What is the applicant's anticipated discharge date?* MM slash DD slash YYYY Please provide the name and contact info of the applicant's Social Worker/Case Worker at the facility.*What is the applicant's primary disability and their prognosis?*What was the applicant's date of onset?* MM slash DD slash YYYY What type of mobility device does the applicant use?* How long has the applicant lived at their current address?* Does the applicant plan on moving in the next 5 years?* Yes No If yes, where?* What is the applicant's current level of income? $0-$25,000 $25,001-$50,000 $50,001-$75,000 > $75,000 What is the applicant's expected level of income in the next 2 years? $0-$25,000 $25,001-$50,000 $50,001-$75,000 > $75,000 If awarded a USAofVA Ramp Project ramp, how would the applicant's life be positively impacted? (Minimum 100 words)*If USAofVa is unable to award you a ramp, how will your life be negatively impacted? Do you have a back up plan to modify your residence?*Please describe the entrance where a ramp would be best installed (ie number of steps, height of steps, etc).*I agree to allow USAofVa to use my likeness (picture, quotes, story, etc) in promotion of current and future USAofVa programming.* I agree to this policy.I, the applicant, provided true and honest information to the best of my ability and understanding.* I agree with this statement Δ