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 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 can attach extra pages.

   The Secretary of the American Council of the Blind of Oregon is:
   Darian Slayton Fleming
   503-253-9543 (home))
   503-522-3272 (cell)
   Postal address: 12616 NE Prescott Dr.
   Portland, OR 97230
   Email the ACB of Oregon Secretary
   11:48 AM 1/19/2012Email address: darehart56@hotmail.com

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 Oregon Commission for the Blind, please sign their Release Form. (You can find a copy of the form below.)
7. No Electronic Forms or letters will be considered. Forms must be signed by the Applicant.
8. Forms must be filled out in full by the Applicant or care provider. No Applications written and submitted by a vendor will be considered.
9. A complete list of equipment and software must be submitted with Application Form.
10. Applicant must Provide Name, Address, and phone number of manufacturer or vendor from which equipment and software is to be purchased.
11. The American Council of the Blind of Oregon Board of Directors reserves the right to limit amounts on Grants at any time.
12. Application must be legible and filled out in full or will not be considered.
13. Please provide two letters of reference (no relatives).

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

Date of Application:________
Name:___________________
Mailing Address:____________________

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Phone Number (include area code):_____________

Is applicant legally Blind? Yes___No___

Is applicant registered with the Oregon Commission for the Blind? Yes___No___

If not listed please attach proof of legal blindness: (Information maybe provided by your Doctor).

Is the applicant a student: Yes__ No__

If yes, where: (name of school, address and phone number).____________________

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Educational Background

High School Graduate Yes___No____

If not number of Grades Completed _____

Name and Address of school

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College Graduate Yes ___No____

If not number of years Completed______

Name and Address of school

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Name of Parent or Guardian:

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

Purpose of the grant-in-aid (Please provide narrative of more than 25 words but less than 50).

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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):
attach list if necessary.

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

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Please provide a brief narrative ( 50 to 75 words), about yourself.

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Signature of applicant or guardian:

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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. 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

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______________Re: SSN:

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______________ 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

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______________ visual acuities, prognosis, visual fields)

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______________ Medical information

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Social/psychological information

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Academic information

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Other information:

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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 Oregon Council Of The Blind

Copyright © 2008 American Council of the Blind of Oregon