Nebraska Greats Foundation Grant Application

I certify that the information I have provided to Nebraska Greats Foundation is accurate and correct to the best of my knowledge and ability. I understand that any misrepresentation or falsification of information on this form will void my application. I further understand my request will be treated with confidentiality. However, I also understand that the Nebraska Greats Foundation may seek additional pertinent verification of the information provided on this application and I expressly consent to such inquiries.

Your application must also include:

1. Letter from you attending physician verifying your condition
2. Copies of bills or medical estimates relevant to the assistance for which you are applying –
3. Two months copies of pay stubs from your employer (if employed)
4. Three months bank statements (checking or savings) verifying your income and expenses

Any additional supporting documentation that will help us to understand your circumstances

Please mail applications to:

Nebraska Greats Foundation Attention:

Sandy Zoroya 5010 Underwood Ave Omaha, NE 68132

Phone: (702) 321-9136

THE FOLLOWNG INFORMATION IS OPTIONAL

NOTE: The decision on your application is not based upon you filling or not filling out this form. Your application is reviewed independently, and you are NOT required to fill out this form. This is a voluntary form we use to help assist you by providing your information to others who may be able to provide support to you and raise the funds needed to help other former, fellow Nebraska athletes.

One of the ways we can help all players and their families who contact us is to get the word out about the medical situations among our former Nebraska athletes. We are asking for your permission to tell your story to potential donors and if you allow the media and public. We will share a general description of your story and possibly a general description of your current injuries. We will NOT disclose financial or medical information from doctors, hospitals, etc., unless you specifically authorize below. An example of what a release would sounds like would be “John Doe, former athlete at the University of Nebraska has lingering health issues. Because this issue is difficult, he has medical bills that exceed his income and family assets. “

You will have complete APPROVAL over any part of your story shared with the media or public. We would also like to publish any appreciation or other notes you send to us. Initial in appropriate columns to indicate authorization for release of the following information: Item Release to Donors Release to Media or Public Injuries/illness Use of Name Release of Medical Information Photos (from playing days) Thank you notes By signing below, you grant the Nebraska Greats Foundation, the authority to publish relevant information we receive from you in order to raise funds for your fellow former Nebraska athletes. You MAY revoke this consent at any time by writing to us.