The Ultimate Assist Application Form

(585) 424-4625
[email protected]

Please complete the below application with information on whom the application is being submitted for—yourself, your family member, or someone you'd like to nominate. Upon receipt of the application, a member of the Iceplex team will follow up with the person applying with next steps.

The Ultimate Assist APPLication

* Indicates required field

First Name of Individual Completing Application Form *

Last Name of Individual Completing Application Form *

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

First Name (Grantee) *

Last Name (Grantee) *

Age of Grantee *

Please tell us about your athlete (or if applying as an individual, yourself), and why you are requesting assistance *

Submit

The Ultimate Assist APPLication

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