Silicon Valley Council of the Blind

A Chapter of the California Council of the Blind

The Barbara Rhodes Adaptive Technology Grant 2018-2019 Application Form

Name:

Address:

Email:

Phone:

Age:

If you need more space to answer the following questions, feel free to attach additional pages to this application form.

1.  What is your visual impairment? Describe your current functional level of vision.

2.  Please provide your approximate monthly income, including wages, retirement, government assistance, etc.

3.  Please provide your approximate monthly expenses, including housing, food, utilities, transportation, etc.

4.  If you currently receive any services from federal, state, city, or other agencies, please explain the type of service you receive.

5.  Tell us about your interests and hobbies, any volunteer work you may have done, and any community organizations to which you belong.

6.  If you are a student, where are you attending school, and at what stage are you in your educational progress?

7.  Describe your current employment, or any past employment experience that you deem relevant.

8.  How did you hear about the Barbara Rhodes Grant?

9.  Explain how you plan to use the grant money.  In answering this question, be as detailed as possible.  For example:

· If you will use the grant for school expenses such as tuition or books, estimate your total expenses, and any resources in addition to this grant that will meet those expenses.

· If you will use the grant to buy a piece of equipment or software, please provide the vendor's name and contact information, the list price, and the item number.  (A photocopy of the page from the catalog or a print-out from the website would be helpful.) Be sure to include sales taxes and shipping charges.

· If the item will cost more than $1500, explain how you plan to pay the balance.

Please submit this completed Application Form by Thursday, February 28, 2019, with the following additional documents:

1.  A personal statement in which you address the following items:

· Please introduce yourself (tell the committee a little about yourself).

· What effect has your vision loss had on your life?

· What product or service do you plan to purchase with these grant funds?

· How will this product or service improve your quality of life?

· Explain why this financial need cannot be met through other funding sources?

2.  Be sure to include a letter from an eye care professional, medical doctor, or blindness professional stating that you are legally blind.

Mail the completed application to:

Silicon Valley Council of the Blind

P.O.  Box 493

Mountain View, CA 94042

In addition to mailing this information, please email whatever items are in electronic form to svcb@onebox.com. You may also submit the application form in electronic format.

Thank you.