Frank Barham Fund Application

Frank Barham Memorial Fund Application

This fund will subsidize RoughRiders for individuals unable to afford the full price. People on public assistance such as Social Security and SSDI will qualify to receive a chair at a greatly reduced price.

Name*
First Last
Email*
Where do you live?*
What kind of wheelchair do you have right now?*
Your Gender
- Male
- Female
Why do you need a RoughRider type of wheelchair?*
Is your upper body strength strong enough to use the Roughrider?*
- Yes
- No
- Unsure
The Roughrider wheelchair weighs 44 pounds and takes good upper body strength to transfer your body into and out of the wheelchair and to put it into and take it out of a car.
Do you have any previous experience using a RoughRider?
Upload your Eligibility Documents*
Drop files here or

Accepted file types: jpg, pdf.
Whirlwind needs a copy of your Public Welfare or Social Security or Medicaid determination letter. You can take a picture of the documents or use a PDF.
Phone
This field is for validation purposes and should be left unchanged.

Frank Barham Fund Application

Frank Barham Memorial Fund Application

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