GRANT APPLICATION FORM

South Central Kentucky Council of the Blind (SCKCB)

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.

1. All requests for grants must be on an SCKCB Grant Application Form, and Submitted to: The South Central Kentucky Council of the Blind Grant Oversight Committee in accordance with the SCKCB Grant Guidelines approved by the SCKCB membership during its January, 2008 monthly meeting. Grant applications can be mailed to: Dr. Ronald E. Milliman, Chair, Grant Oversight Committee, 1564 Normal St., Bowling Green, KY 42101-3535 or e-mailed to: rmilliman@insightbb.com.

2. With the submission of the SCKCB Grant Application Form, you are acknowledging that you have read the SCKCB Grant Guidelines and fully comply with and agree to the conditions set forth in those guidelines.

3. Grant applicants will be notified, in writing (either hard copy or electronically), of the decision within ten days following the Quarterly meeting of the Grant Oversight Committee in which the decision about your application is rendered.

4. An individual seeking matching funds is not eligible if they have already purchased the piece of equipment prior to or at the time of applying for a SCKCB Grant, i.e. any reimbursement for devices already purchased is not allowed.

Please answer all of the following questions:

Date of Application: ________________________________________________________________

Name of the grant beneficiary: ________________________________________________________

Mailing Address: ___________________________________________________________________

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Phone Number (include area code): ___________________________________________________

E-mail address: ___________________________________________________________________

Is the beneficiary of the requested grant legally blind? Yes_____ No_____

If beneficiary is under the legal age of 21, name of Parent or Guardian: ________________________

If beneficiary is under the legal age of 21, address of Parent or Guardian:

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The grant requested is for $______________________________

Purpose of the grant: _______________________________________________________________

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Please provide a detailed description of the item/s, cost and the name of the company from which the equipment is to be purchased. Attach a brochure or catalog copy if available.

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Please describe how the attainment of the device for which the grant funds will be used will benefit the user:

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Since the SCKCB grant provides up to a maximum of 50% of the purchase cost of the device for which the funds are intended, from what source will the remaining 50% come? (Please provide evidence of these matching funds)

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Signature of applicant (if of legal age) or parent/guardian:

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