Neilsen Foundation Athlete Grant Application

For Information or questions :
e-mail Phil Galli
philg1234@comcast.net or
Call – 908-240-7641

Fill in Form and Submit


First Name Last Name Sex ASUSA Number
Address 1 Address 2 City ST ZIP
Date of Birth (MM/DD/YY) Age Group    Athlete Contact E-mail
U    Archery   
Team Coach / Parent / Guardian
Coach or Parent/Guardian if Independent
Telephone # SCI DISABILITY SCI CAUSE SCI OTHER (EXPLAIN)

First NJDC?     Check if Yes

Track             Class             20m 40m 60m 100m 200m 400m 800m 1500m 3000m 5000m
Field              Class             Softball Club Discus Javelin ShotPut
Swim    Class S SB SM       F25 F50 F100 F200 F4/500
                   BK25 BK50 BK100 BK200  
                   BRST25 BRST50 BRST100 BRST200  
                   FLY25 FLY50 FLY100 FLY200  
                   IM75 IM100 IM150 IM200  
Archery         Class   
Powerlift       Class