Youth Services Grant Application

MCB Youth Services Grant Program

Provides up to $225 per year for educational and vision-related items for blind and visually impaired children in grades K–12.

Child's Information

Child's Full Name

Is the child legally blind?

Yes

Child's Street Address (if different from applicant)

City

State

ZIP

Applicant Information

Form completed by

Parent

Guardian

Teacher

First Name

Last Name

Street Address

City

State

ZIP

Phone

Vendor Information

Preferred Vendor / Supplier

MCB may purchase items directly from this vendor on your behalf.

Requested Items

List each item you are requesting. The total may not exceed $225.00 per year.

Qty	Item No.	Description	Amount ($)	Remove






Total Requested:			$0.00

Certification & Signature

I certify that all information provided on this application is true and accurate to the best of my knowledge. I understand that the MCB Youth Services Grant may be used only for the items listed above, and that receipts may be required.

Electronic Signature (type your full name)