GRANT APPLICATION FORM

GRANT APPLICATION FORM

A.C.B. of OREGON

(dba) OREGON COUNCIL of the BLIND INC.

1. All requests for grants must be on an American Council of the Blind of Oregon Grant Application Form and submitted to the Secretary of the American Council of the Blind of Oregon.  You can print a copy of this page and use it as your application form.  If you need more room than is provided, you may attach extra pages.

2. The Secretary of the American Council of the Blind of Oregon is:

              
        Darian Slayton Fleming
        (503) 253-9543 (home)
        (503) 522-3272 (cell)
        12616 NE Prescott Dr.
         Portland, OR  97230
dlsfleming@gmail.com              

Grant requests must be received by January 1, April 1, July 1 and October 1. 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 the quarterly Board meeting.

4. All applicants must be legally blind.

5. All applicants must be a resident of Oregon.

6. If registered with the Oregon Commission for the Blind, please sign their Release Form.  (You can find a copy of the form below.)  This is submitted with the application.

7. If one or both references or another entity may be contacted for further information about the applicant’s situation or need, please complete and sign the attached Other Service Providers Information Release Authorization form and submit it with the application.

8.  If at all possible, complete this form in a word processing program on a computer so that board members who are blind may scan and read it.  Handwritten applications will not be accepted due to difficulties with character recognition scanning software.

9. No electronic forms or letters will be considered unless hard copies are mailed as well.  Please send two copies of the application packet to the ACB of Oregon Secretary.

10. Forms must be signed by the applicant.

11. Forms must be filled out in full by the applicant, care provider or other assistant.  Applications written and submitted by vendors will not be considered.

12. A complete list of equipment and software must be submitted with application form.

13. Applicant must provide name, address and phone number of manufacturer or vendor from which equipment, software or activity is to be purchased (funds will go directly to the vendor or agency).

14. The American Council of the Blind of Oregon Board of Directors reserves the right to limit amounts on grants at any time.

15. In order to be considered, applications must be legible, signed by the applicant or parent/guardian and completed in full.

16. Please provide two letters of reference (no relatives).  If references are professionals, please include signed information release authorizations from those providers with this application.  Each reference must include phone number and/or e-mail address.

(DBA) OREGON COUNCIL OF THE BLIND GRANT APPLICATION

Date of application:

Name:

Mailing address: 
                              

 

Phone number (including area code):

Is applicant legally blind:

Is the applicant registered with the Oregon Commission for the Blind:

If not registered with the Commission, please attach a separate proof of legal blindness (Information may be provided by your Doctor):

Is the applicant over 21 years of age   Answer “Yes, I am over 21 years of age” or “No, I am 21 or under 21 years of age”:

 

Is the applicant a student   Answer “Yes, I am a student” or “No, I am not student”:

 

If the answer is “Yes, I am a student”
                             Name of school:

                             Address of school:

 

                              Phone number of school:

Is the applicant a high school graduate:

 If not a high school graduate, what number of grades completed:

                          Name of the school:

                          Address of the school:

 

Is the applicant a college graduate:

If not a college graduate, what number of years completed:

             Name of the school:

             Address of the school:

 

Name of Parent or Guardian if under age 18:

Dollar amount for which applicant is applying for the grant:

Purpose of the grant, please provide narrative of more than 25 words but less than 50 words:


If the grant is for equipment, please provide the following information:
               (1) Name of company purchasing from:

               (2) Address of same company:

 

               (3) Phone number:

               (4) Contact person or department:

               (5) Order number:

                (6) Dollar amount for which applying:

                (7) Description:

 

If the grant is for equipment from a second company, please provide the following information:

              (a) Name of company purchasing from:

              (b) Address of the same company:

              (c) Phone number:

              (d) Contact person or department:

              (e) Order number:

               (f) Dollar amount for which applying:

               (g) Description:

If the grant is for equipment from a third company, please provide the following information:

Name of company purchasing from:

Address of same company:

 

                                             Phone number:

                                             Contact person or department:

                                             Order number:

                                            Dollar amount for which applying:

                                           Description:

 

If not for equipment or education, please describe purpose of the grant and what amount of money is requested:


 

List other organizations or agencies to which the same request is pending:

 

 

 

Provide a brief narrative of 50 to 75 words about yourself:

 

 


 

Provide two references:
                Name of the first reference:

                Address:

                Phone:

                E-mail:

                Name of the second reference:

                Address:   

 

                 Phone

                 E-mail:

Attach letters with the signature of the providers and Information Release Authorizations for each, if applicable. 

If registered with the Oregon Commission for the Blind, please sign the following Release Form.

You may submit any other information that you wish the ACB of Oregon Board of Directors to consider.  Additional information may include a personal interview.  Financial status may be requested by the Board of Directors.
 

OREGON COMMISSION FOR THE BLIND
Release of Information Request Form

Staff person:  VR IL Other
OREGON COMMISSION FOR THE BLIND
535 SE 12TH Ave   Portland, OR  97214
(503) 731-3221

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:

          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:


OTHER SERVICE PROVIDERS
Release of Information Request Form

Name of agency:

Name of provider:
Title (I.E. Vision Teacher, Occupational Therapist (OT):

Address:

 

Phone:

E-mail:

Release of information request to:        ACB of Oregon
                                                               Darian Slayton Fleming
                                                              12616 NE Prescott Dr.
                                                              Portland, OR  97230
                                                              (503) 253-9543 (home)
                                                              (503) 522-3272 (cell)
                                                              Darehart56@hotmail.com

Re SSN:

I authorize (fill in agency or name)                                                           

to release the specified information:

            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:

 

OTHER SERVICE PROVIDERS


Release of Information Request Form

Name of agency:

Name of provider:

Title (I.E. Vision Teacher, Occupational Therapist (OT):
Address:

 

Phone:

E-mail:

Release of information request to:        ACB of Oregon
                                                              Darian Slayton Fleming
                                                              12616 NE Prescott Dr.
                                                              Portland, OR  97230
                                                              (503) 253-9543 (home)
                                                              (503) 522-3272 (cell)
                                                             Darehart56@hotmail.com

Re SSN:

I authorize (fill in agency or name)                                                                           
to release the specified information:

              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: