The Ultimate Assist Application Form

ULTIMATE ASSIST

Fill out the application form below, providing details about the individual for whom you are submitting the application—whether it's for yourself, a family member, or someone you wish to nominate. Once we receive your application, a member of the Iceplex team will reach out to guide you through the 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

ULTIMATE ASSIST