KSBCF BRAILLE WRITER LOAN PROGRAM APPLICATION

 

GUIDELINES FOR USE OF PERKINS BRAILLE WRITER

  1. I will assume full responsibility for the braille writer's safe keeping and care.
  2. I will not sell, loan or rent the braille writer to another person.
  3. I will return the braille writer to KSBCF as needed for routine cleaning and maintenance.

    For cleaning/maintenance/repairs, mail braille writer to:
    KSB Charitable Foundation
    214 Haldeman Avenue
    Louisville, KY 40206

    (Please include any notes regarding issues that need repaired
    and enclose the mailing address to which the device should be returned.)


  4. I will not remove any identifying information or labels from the braille writer..
  5. I will not allow anyone except KSBCF Braille Repair to do any maintenance or repairs on the braille writer loaned to me.
  6. If I move out of the state of Kentucky, I will return the braille writer to KSBCF.
  7. If I move within the state, I will notify KSBCF of my new address.

I have read, understand and hereby agree to comply with the above guidelines.

_______________________________________________________
(Signature and Date)

_______________________________________________________
Parent/Guardian signature and date (if applicant is under 20)

A signed copy of these guidelines must be submitted with your application.
Please keep a copy for your own records.



Name:________________________________________ Birth Date: _____ / _____ / _____

Address:___________________________________________________________________

City:_______________________________________State:___________Zip:_____________

Phone:(home)_________________(work)___________________ (cell)_________________

E-mail Address:______________________________________ County: ________________

How long have you been using braille in your everyday activities?_____________________

Please choose: Student ______ (Grade Level _____ ) Employed _____ Unemployed _____

Current School / Employer: ___________________________________________________

_________________________________________________________________

Name of TVI (Teacher of the Visually Impaired): ___________________________________

Are you an Office for the Blind (OFB) client? ____ Yes ____ No

If yes, please list the name of your OFB counselor: ________________________________

You must submit the following documents with your application:

  • A current eye exam or verification of legally blind status
  • A letter of recommendation from a teacher, counselor or other professional (if in school)
  • A letter from your rehabilitation counselor (if you are an Office for the Blind client)

I hereby state that I answered the above information accurately and to the best of my ability.

_______________________________________________________
(Signature and Date)

_______________________________________________________
Parent/Guardian signature and date (if applicant is under 20)


Please send your application and supporting documents to:

Kentucky School for the Blind Charitable Foundation
214 Haldeman Ave.
Louisville, KY 40206

OFFICE USE ONLY:

Date request received: ___________________ Reviewed/Approved by: ______________________

Braille Writer ID#: _________________________ Serial#: _________________________________