Eye-Link Foundation — Grant application

Eye-Link Foundation Grant Application

The Eye-Link Foundation provides Grants to Blind and Visually impaired residents of Minnesota for Assistive technology and or associated training. The Eye-Link Board reviews and makes decisions on Grant applications on a quarterly basis. Their decisions are final. Applicants will be notified of their status within two business days following Board review. Grants will be sent to authorized Vendors after being invoiced. The Eye-Link Committee reserves the right to deny funding for any reason. This process and form may be changed at any time without notice.

Applications are available in Braille by calling the Foundation at 763-561-6967. Requests for Braille applications or questions regarding the application process may also be sent by E-mail.

applications@eye-link.org

You must be on file, either as active or inactive, with State Services for the Blind (SSB).

You must have been turned down by SSB for the technology or training for which you are applying.

Mail your application to:

The Eye-Link Foundation
J. H. Justesen
6800 Willow Lane
Minneapolis, MN 55430

1. Name:

2. Home Address:

3. City: State: ZIP:

4. Home Phone: Work Phone:

5. E-Mail (if available):

6. Current student? Yes No

7. If yes, what type of school or training?

8. Are you currently a client of State Services for the Blind (SSB)? Yes No

9. If yes, name of Counselor: Phone:

10. If no, have you been a client in the past? Yes No

11. If yes, when was your case closed?

12. Former counselor’s name (if known): Phone(if known):

13. Specify type/model of equipment or training you need:

14. Approximate total cost (if known):

If active client of SSB please answer the following:

15. How was need for this equipment/training determined?

16. Have you asked SSB to buy the needed equipment? Yes No

17. Status of request: Active Closed Denied

18. If denied, why?

19. If denied, was your right to appeal given to you? Yes No

20. Have you appealed? Note: Your application will not be processed if you have not appealed and a letter of denial is not attached. Yes No

21 If yes, status of appeal:

22. Unaware of right to appeal

The following is optional but would assist Eye-Link in making a prompt response:

I give Eye-Link representatives permission to contact my SSB Counselor on questions
related to the specific equipment I am requesting Eye-Link to purchase for me.

Signature: _________________________ Date: ____________