Eye-Link Wisconsin Grant Application

Full Name *(required)

Address *(required)

Address line 2 (optional)

City, State, Zip *(required)

Phone

Email *(required)

Are you currently a client of any state agency? (WI Dept of Health, WisTech, OBVI or any low vision-related facility)

YesNo

Counselor or vision specialist

Equipment request *(required)

Permission to contact counselors (optional)

I give Eye-Link representatives permission to contact current or former vision counselors with questions related to this grant.

YesNo

Signature and date

Attach grant applicationAttachments (0)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Mail donations to:

Eye-Link Wisconsin
P.O. Box 865
Green Bay, WI 54305

Eye-Link Wisconsin
Attn: Gabriel DeLeon
4535 West Holmes Avenue
Greenfield, WI 53220
+1.922.360.7258

Eye-Link Wisconsin