EmailMeForm
NCSCIA Hurricane Helene Relief Grant
Name
*
Email
*
Email Confirmation
Phone Number
*
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Mailing Address (Please include Apt. Number, if applicable)
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Injury Type and Level
*
Please provide a brief description of the challenges you are experiencing due to Hurricane Helene.
*
If approved, how will you use this Disaster Relief Grant?
*
Do you have Hurricane Helene related needs that exceed this $500 threshold? If so, please describe these needs so that we can assess our ability to meet this need following our initial distribution of funds.
Additional Comments/Questions:
Additional Information:
Please select all that apply to you.
Gift Card Choice
VISA Gift Card
Walmart Gift Card
Are you members of NCSCIA? (www.ncscia.org)
Yes
Are you a member of United Spinal? (www.unitedspinal.org)
Yes
