Wisconsin Grant Application

wi_application_ia_7-24.pdf
File Size:	107 kb
File Type:	pdf

Download File

Eye-Link Wisconsin Assistive Equipment Grant Application

Eye-Link Wisconsin provides assistive equipment/technology grants to Wisconsin residents experiencing uncorrectable loss of their sight. Eye-Link welcomes all applicants. The application can be completed and submitted online at wi.eye-link.org or you can email a copy directly to our Director of Applications Jeffrey J. Scott at [email protected].

The Eye-Link Board of Directors reviews and makes decisions on all grant applications on a date received basis. Approved grants may include either new or refurbished equipment. All applicants will be notified of their application status within two business days following Board review.

* Indicates required field

Full Name *

First

Last

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone *

Cell or Work Phone *

Email address (if available) *

Are you currently a client of any state agency like the Wisconsin Department of Health Services’ Assistive Technology Program (WisTech), or any low vision-related facility? *

Yes No

If yes, please provide the name of facility or counselor *

Counselor phone # *

How was your need for the equipment/training you are requesting determined? *

What type, model or description of adaptive technology and/or training are you requesting from Eye-Link Wisconsin? *

The following is optional but would assist Eye-Link Wisconsin in providing a prompt response to you.

I give Eye-Link Wisconsin representatives permission to contact any former counselors on questions related to the specific equipment that I am requesting to have Eye-Link purchase for me.

Signature *

Date *

Application can be submitted online or emailed directly to: [email protected]
For more information visit wi.eye-link.org or call Jeffrey Scott at 608-695-1836 if you need assistance.

Submit

Eye-Link Wisconsin Assistive Equipment Grant Application

CONTACT US

SEND APPLICATIONS TO:

BOARD OF DIRECTORS