Silicon Valley Council of the Blind

A Chapter of the California Council of the Blind

The Barbara Rhodes Access Technology Grant 2022 Application Form

Name: ______________________________________

Address: ______________________________________

_______________________________________________

Email: ___________________________________

Preferred phone: ____________________

Alternate phone (optional): ____________________

Select the range that corresponds to your age:

__ 16-25

__ 26-40

__ 41-64

__ 65 and above

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

_______________________________________________

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

_______________________________________________

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

_______________________________________________

5. Explain how you plan to use the grant. 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.
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, but is not required.)
If the item will cost more than $1,500, explain how you plan to pay the balance.

_______________________________________________

Please submit this completed application form, postmarked no later than March 31, 2022, with the following additional document:

A 200-word personal statement in which you tell your story more fully. Please address the following items:

1. Tell the committee a little more about yourself.

2. What impact has your vision loss had on your life?

3. How will the product or service you wish to purchase improve your quality of life?

_______________________________________________

Again, if you have questions, would prefer an application in braille, or need assistance filling out the above application, please leave a voicemail at: 888-652-5333, or send an email to: svcb@onebox.com

Mail or email the application form, the personal statement, and any supporting documents to:

Silicon Valley Council of the Blind

P.O. Box 4116

San Jose, CA 95125

Thank you.