GRANT APPLICATION FORM

A.C.B. of OREGON
(dba) OREGON COUNCIL of the BLIND INC.

1. All requests for grants, must be on an Oregon Council of the Blind, Grant Application Form, and Submitted to: The Oregon Council of the Blind Inc. O.C.B. Board of Directors
   You can print a copy of this page and use it as your application form.
   If you need more room than is provided, you can attach extra pages.
2. The Board of Directors at their next regular quarterly meeting, will take up the request, and make a decision at that time.
3. Grant applicants will be notified, in writing, of Board action within ten days following Quarterly Board Meeting.
4. All applicants must be legally blind
5. All applicants must be a resident of Oregon
6. If registered with the Commission for the Blind, please sign their Release Form.
   (You can find a copy of the form below.)

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A.C.B. of OREGON
(dba) OREGON COUNCIL OF THE BLIND
GRANT-IN-AID, APPLICATION:

Please answer all questions:

Name:

Mailing Address:

Phone Number (include area code):

Is applicant legally Blind?

Is applicant registered with the Oregon Commission for the Blind?

If not listed please attach proof of legal blindness:

Is the applicant a student: Yes__ No__

If yes, where:

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Name of Parent or Guardian:

The application for, grant-in-aid is for $____

Purpose of the grant-in-aid:

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If the grant is for education, please give the name of the institution.

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If the grant is for equipment, please provide a description of the item/s, cost and the name of the company from which the equipment is to be purchased.

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Other purpose of the grant-in-aid (please describe):

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Attach list if necessary.

List other organizations or agency to which the same request is pending..

> Signature of applicant or guardian:

__________________________

Please note: Sign the Oregon Commission Release Form & Submit any other information that you wish the Board of Directors to consider.
Additional information may include a personal interview, or financial, status, may be requested by the Council Board of Directors.

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OREGON COMMISSION FOR THE BLIND
Release of Information Request Form

OREGON COMMISSION FOR THE BLIND
535 SE 12th Ave Portland, OR 97214
(503)73 1-3221

Release of Information Request

To: Re: SSN:

I authorize you to release the specified information to the Oregon Commission for the Blind.

I authorize the Oregon Commission for the Blind to release the specified information to you. (X)

Eye information (diagnosis, best corrected

visual acuities, prognosis, visual fields)

Medical information
Social/psychological information

Academic information

Other information:

This information will be used in my behalf and will not be released to a third party without permission.

This release expires one year from date of signature.

Client Signature_____________________________

Date______________

Copyright © 2003 by The Oregon Council Of The Blind