Application

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Eye-Link Wisconsin Assistive Equipment Grant Application

Eye-Link Wisconsin provides assistive technology grants for assistive/adaptive equipment to blind and visually impaired residents of Wisconsin. The Eye-Link Wisconsin Board of Directors reviews and makes decisions on all grant applications on an as received basis. Approved grants may include either new or refurbished equipment. The Eye-Link Wisconsin Board reserves the right to deny funding of a grant for any reason. Their decisions are final. This process and form may be changed at any time without notice. Applicants will be notified of their application status within two business days following the Board review. Visually impaired and blinded veterans should apply for adaptive equipment through their local VA.

Please mail your application to:

Eye-Link Wisconsin
Attn: Jeffrey J. Scott
201 North Walbridge Avenue
Unit 116
Madison, WI 53714

* Indicates required field

Full Name *

First

Last

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone *

Mobile or Work Phone *

Email address (if available) *

Currently a student? *

Yes No

If yes, what type of school or training? *

Are you currently a client of any state agency like WI Assistive or low vision rehabilitation facility? *

Yes No

If yes, name of facility, counselor and phone number *

If no, have you been a client of any rehab facility in the past? *

Yes No

If yes, approximately when was your case closed or your training completed? *

If you are an active client of any training agency, please answer the following:

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

If your equipment request was denied by any agency or non-profit organization, what reason were you given? *

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

Have you ever been a member of the Armed Forces or Reserves? *

Yes No

If yes, what branch? *

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 *

For more information visit wi.eye-link.org or call Jeffrey Scott (608) 692-6358.

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Eye-Link Wisconsin Assistive Equipment Grant Application

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BOARD OF DIRECTORS