CHALLENGE THE OUTDOORS--ADAPTIVE EQUIPMENT APPLICATION
DATE: ______________________ PHONE NUMBER: ( )- -
CITY: _____________________________________________________ STATE_______
PLEASE SIGN HERE--_______________________________________________________
WHAT ITEM ARE YOU ASKING TO BE CONSIDERED FOR ADAPTIVE EQUIPMENT REIMBURSEMENT?
WHAT IS THE ITEM GOING TO BE USED FOR?
*HOW HAVE YOU SUPPORTED “CHALLENGE THE OUTDOORS” DURING YOUR MEMBERSHIP OVER THE LAST YEAR(S)? PLEASE EXPLAIN. (Use the back of the application for more room to write)
*MEMBER IN GOOD STANDING: If you receive money assistance, we ask that you give back to the organization by helping and supporting us as you are able. We need to share both ways. Just ask how you can help.
CHALLENGE THE OUTDOORS ADAPTIVE EQUIPMENT RULES: All required
· The Adaptive Equipment program applies to hunting and fishing equipment only and is for disabled members only.
· Approval will be done by the committee or committee with the board of directors at a board meeting.
· You may receive only one Adaptive Equipment reimbursement one time per year.
· The year runs from January 1 to December 31.
· You must be a paid member of CTO for one full year before you are able to use the adaptive equipment program and continue to pay your dues each year.
· You must provide CTO with the original receipt, and the receipt must provide the name of the store, address, phone number, current date, and cost of the article printed out on the receipt.
· Written or adjusted receipts are not accepted.
· You must completely fill in, sign, and date the application for it to be considered.
· The reimbursement is to be 1/2 the cost of the item up to a maximum of $100.
· For those items that need to be made adaptable, only the adaptable part is considered for program.
Do not cut apart
PLEASE DO NOT WRITE BELOW THIS LINE
ADAPTIVE EQUIPMENT ACCEPTED
ADAPTIVE EQUIPMENT DENIED
IF DENIED, THE REASON____________________________________________________
NOTE: Please return this full application and the original receipt to our Office— to this address
Challenge The Outdoors, Inc.
Home Instead Senior Care
901 Anderson Drive--Green Bay, WI 54304
For questions please call Pat at 920-687-8707
Version made April 17, 2017 slf