MCB Program Application

PERSONAL DATA
First Name
Last Name
Country
Address Line 1
City
State
Postal Code
VISUAL STATUS
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MEMBERSHIP
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Have you previously received a MCB Adaptive Technology grant?
$

SUPPORTING DOCUMENTS

  • The exact specifications of the adaptive technology or computer to be purchased.
  • A copy of an official price quote from two (2) vendors
  • Written verification of legal blindness from an Ophthalmologist or other reasonable authority (obtained within the past year) including a description of the applicant’s eye condition, visual  acuity and field of vision.

Statement of Agreement

I have read the entire document titled “Missouri Council of the Blind Adaptive Technology Grants Program,” and I understand and agree to all terms and conditions contained therein. All information that I have listed on this application form is accurate to the best of my knowledge and correct to the best of my ability. I understand and agree that any failure on my part to wholly comply with the “Missouri Council of the Blind Adaptive Technology Grants Program” or “Missouri Council of the Blind Adaptive Technology Grants Application Form” may void this application or otherwise render me ineligible for a MCB matching funds grant.

By checking this box you sign this application

*To verify blindness, Applicant must complete name, address and phone number of the physician; sign and date this Release Form and enclose it with the application.

I hereby authorize the following named physician, ophthalmologist, organization, agency or other qualified authority to provide Missouri Council of the Blind any requested information about my eye condition, visual acuity and field of vision:

First Name
Last Name
Country
Address Line 1
City
State
Postal Code
By checking this box you sign this application