Youth Services Grant — Medical Summary

About This Form

This Medical Summary must be completed by an ophthalmologist, optometrist, or other qualified eye care professional as part of the MCB Youth Services Grant application.

This form must be completed within 12 months of the grant application date.
The eye report must include the participant's name, date of birth, and diagnosis.
It must also include the name, address, and phone number of the examining professional or organization.
Alternatively, an eye report letter on professional letterhead may be mailed or emailed to MCB instead.

Youth Services Grant Application

Required field

Applicant Information

Applicant's Full Name

Date of Birth

Date of Examination

Examining Professional

Professional's Name

Specialty / Title

Vision Verification

Is the applicant legally blind?

Yes

Description of Vision Condition

Additional Medical Information

Are there any other medical conditions relevant to the grant request?

Yes

If yes, describe conditions or limitations

Professional Signature

This form must be completed within 12 months of the grant application date.

Professional's Signature

Date

Download a Form

Printable PDF (PDF, 32 KB)Word Document (Word, 47 KB)

Fill in the Word document on your computer and email it to aa@moblind.org.

Mail completed form to:

Missouri Council of the Blind
5453 Chippewa Street
St. Louis, MO 63109

Or email: aa@moblind.org

Questions?

(314) 832-7172

moblind@moblind.org