KSBCF GRANT APPLICATION

Requirements for submission of grant requests:

  • Requests for funding will only be accepted through submission of a grant application.
  • Application Deadline: Requests must be submitted by April 1 or October 1 for consideration.
  • Applicants must be blind or visually impaired and a resident of Kentucky or must be an organization that serves those who are blind or visually impaired in Kentucky.
  • Applicants who need assistance completing grant forms or require a specific format may contact our office at (502) 897-3990.
  • Incomplete applications and/or applications without supporting documents will be returned.

Applicants must submit the following documents with the application:

  • Student applicants grades K-12 must include a copy of the student IEP, Assistive Technology Evaluation and/or Learning Media Assessment.
  • Student applicants grades K-12 must include a letter from a Teacher of the Visually Impaired (TVI) specifying the need for the equipment/grant.
  • College student applicants must submit a letter of recommendation from a teacher, counselor or other professional.
  • Office for the Blind (OFB) clients must submit a letter of recommendation from an OFB counselor.

INDIVIDUAL APPLICANT

Name: ______________________________________________ Birth Date: _____ / _____ / _____

Address: ________________________________________________________________________

City: _____________________________________ State: ______________ Zip: ______________

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

E-mail address: ___________________________________________________________________

Is the applicant a student?: _______Grade Level: __________ TVI: _________________________

School Attending:_________________________________________________________________

Is the applicant a client of the Office for the Blind? ______ Counselor: _______________________

Is the applicant enrolled in: Vocational Training _____ College Courses _____ Other: ___________

Name of College/Workplace: ________________________________________________________

Eye Condition / Acuity: ____________________________________________________________

Name of parent/guardian (if applicable): ________________________________________________


ORGANIZATION APPLICANT

Contact: __________________________ Executive Director/Administrator:___________________

Organization: ____________________________________________________________________

Address: ________________________________________________________________________

City: _____________________________________ State: ______________ Zip: ______________

Phone:_____________________ Website: ____________________ Email: __________________

Is the organization a 501(c)(3)?: _____ If so, please provide Federal ID number :______________

Number of employees: _________________ Annual operating budget: ______________________

Services provided: ________________________________________________________________

_____________________________________________________________________

Mission statement: _______________________________________________________________

_______________________________________________________________________________

Type (adults, children, elderly, etc.) and number of population served: _____________________

_______________________________________________________________________________

Grant Request

You must include either a dollar amount for a grant funding request or list the type of assistive technology requested with an estimated cost.

Grant dollar amount requested (if applicable): $____________________

Assistive technology requested (if applicable): ________________________________________

Estimated cost of assistive technology: $ ________________________

Purpose of the Grant:

This section must include a detailed description of the request (i.e. provide the reason for the request/need, the specifications of assistive technology/equipment, how the grant or technology will make a difference to your current situation, date by which you need the funding or device, etc.) and a budget and/or itemization of cost. You may attach additional pages or documents, if needed.

_____________________________________________________________________

_____________________________________________________________

_______________________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

If requesting technology, is the device needed for education or employment purposes?

______________________________________________________________________________

How will the device benefit the applicant? ____________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Has the applicant had an assessment by a Low Vision Specialist, TVI, OFB Technology Specialist or other appropriate evaluation? YES _____ NO _____ (If YES, please attach a copy of the assessment)

Does the applicant know how to effectively use the requested device or will the applicant need training? If so, who will provide the training?
______________________________________________________________________________

______________________________________________________________________________

Has funding been requested from any other source (i.e. school system, special education cooperative, Office for the Blind)? YES _____ NO _____

If yes, list the organizations or agencies to which you requested funding:

______________________________________________________________________________

What is the status?: Pending _____ Funded _____ (Amount $_________) Not Funded _____

If not funded, please list the reason for denial:________________________________________

_____________________________________________________________________________

_______________________________________________________________________________

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

Signature of Applicant: ________________________________________ Date: ______________


Please submit this application to:


Kentucky School for the Blind Charitable Foundation

Attn: Grant Review Committee
214 Haldeman Avenue

Louisville, KY 40206

Phone: (502) 897-3990 | Fax: (502) 897-3194 | Email: contactus@ksbcf.org

OFFICE USE ONLY

D
ate Application Received:_______________ Notes:____________________________________