Grant Application All required fields are marked with an * "*" indicates required fields 1Grant Type2Your Information3References4Your request5Your need6Certification7Preview and submit Do you live in or provide services in Alameda or Contra Costa Counties in California?*Applicants must live in Alameda or Contra Costa Counties in California or provide services for individuals who are blind or low vision in these counties. Yes No You are not eligible for a grant because you live outside of Alameda or Contra Costa Counties, California, or do not provide services to residents of those counties. If you have any questions, please contact us.What type of grant are you applying for?* Dr. Maureen Powers Quality-of-Life Grant (QOL) Ed Cossart Immediate Needs Grant (IN) Grant descriptionThe purpose of LVRN grants is to provide financial aid to blind or low vision individuals to improve their quality of life. Dr. Maureen Powers Quality-of-Life Grants (QOL) are awarded throughout the year with a limit of $5,000 for any single grant. QOL Grants are limited to blind or low vision individuals 21 years old or older who live in Alameda or Contra Costa Counties in California or to organizations that serve blind and low vision individuals in these counties. Applicants can receive more than one grant, however there is a one-year waiting period between receiving QOL grants. There is no income limit. Certification of blind or low vision status by a professional third party is required. Those who have received prior funding will receive lower priority than first-time applicants. Please note that filing an application for a grant is not a guarantee that a grant will be awarded. The QOL is designed to fund the following needs: Smartphones and tablets and related training to enhance accessibility Computers – Applicants must have prior computer experience and a demonstrated proficiency with a computer Braille equipment and Braille training Low vision products, including training Equipment that aids in safety at home The list is meant to be suggestive and not limiting. LVRN will consider any request, but those that fill gaps in funding provided by the State or other means, or those that are not available through other means, will receive priority. Except for cash grants to organizations or to individuals for research, grant proceeds will not be given directly to an individual. LVRN will purchase the product(s) or service(s), but the grantee will be the owner of any devices and will register the product(s) so that any warranties will be in their name. Any warranty issues will be handled between the grantee and the vendor. LVRN will not participate in that process. Awardees must give a final accounting or testimonial of how the grant was used, the benefits derived from the grant and be willing to have their testimonials used for publicity purposes by LVRN.The purpose of LVRN grants is to provide financial aid to blind or low vision individuals to improve their quality of life. Ed Cossart Immediate Needs Grants (IN) are limited to blind or low vision individuals 21 years old or older who live in Alameda or Contra Costa Counties in California and are awarded throughout the year with the purpose of providing financial aid to those individuals who have a demonstrated immediate, but low cost need. The maximum amount to be awarded is $1,500. Computers are not a part of this program. Smart phones, iPads or Apple watches may be considered, but the cost of the item(s), any warranties or maintenance plan and/or any setup/training expense cannot exceed the $1,500 limit of these grants. Certification of blind or low vision status by a professional third party is required. Please note that filing an application for a grant is not a guarantee that a grant will be awarded. The Ed Cossart Immediate Needs Grant is designed to fund the following types of needs. The list is meant to be suggestive and not limiting. Medical Aids (e.g. Talking Blood Glucose Monitor) Seeing Aids (e.g. Canes or Repair of a Braille Machine) Transportation (e.g. Transit to Medical Appointments, Work Conference or for a Family Emergency) Except for cash grants to organizations or to individuals for research, grant proceeds will not be given directly to an individual. LVRN will purchase the product(s) or service(s), but the grantee will be the owner of any devices and will register the product(s) so that any warranties will be in their name. Any warranty issues will be handled between the grantee and the vendor. LVRN will not participate in that process. Awardees must give a final accounting or testimonial of how the grant was used, the benefits derived from the grant and be willing to have their testimonials used for publicity purposes by LVRN. Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Reference 1 Name* First Last Reference 1 Phone*Reference 2 Name* First Last Reference 2 Phone*Reference 3 Name* First Last Reference 3 Phone* Types of items requested for Ed Cossart Immediate Needs Grant*Please check all that apply Phone iPad Apple watch Products and services other than phone, iPad, or Apple watch Types of items requested for Dr. Maureen Powers Quality-of-Life Grant*Please check all that apply Computer Phone iPad Apple watch Products and services other than computer, phone, iPad, or Apple Watch Notes about requests for phones, iPads, and Apple Watches Please remember that for smart phones, iPads, or Apple watches to be considered under the Immediate Needs Grant program the cost of the item, any Apple Care or maintenance plan and/or any setup/training expense cannot exceed the $1,500 limit of these grants and must be an immediate need. Notes about requests for computers If you are requesting a computer, the type of computer will be determined in a discussion between you and the LVRN computer/technical consultant. The initial setup of the computer, including loading of software, will be done before the computer is either delivered to you or ready for pickup. Notes about requests for other products and services For products and services other than computers, phones, iPads, and Apple watches, please cite the source of where the product or service can be acquired and provide a link to a description of each item or service, if possible. This will ensure that the right product or service is obtained. If you are requesting research funds or funds for an organization, summarize the request and associated costs here as succinctly as possible. Summary of your requestList each product or service requested and the complete cost of each item. You may use the next field to upload a separate document or you can type in this field. Be as specific as possible and include any sales tax or delivery charges, if applicable.Summary of your request (separate document)If you prefer to upload a separate document with the details of your request rather than typing it in the previous field, you may do that here. Word docs, PDFs, and Excel spreadsheets are accepted.Accepted file types: doc, docx, pdf, xlsx, xls, Max. file size: 512 MB.Additional information about your requestPlease complete the following information about the products and services other than a computer, phone, iPad, or Apple watch.Have you used a similar product(s) before?* Yes No Unsure Can you set up the product(s) yourself?* Yes No Unsure Do you have someone who can assist you setting up the product(s)?* Yes No Unsure What type of training do you need?*E.g., in person, one on one, over the phone, etc?Do you need training in a language other than English?* Yes No What language?*Can you travel to Castro Valley for training?* Yes No Unsure Do you have a recording device to record training lessons?* Yes No Unsure If not, how do you take notes?*Additional Information about your phone requestPlease complete the following information about the phone you are requestingPhone model requested*Phone GB Storage*Enter just the number for the GB of storage request, e.g 128Please state why you need more than 256GB storage for your phone*Phone Finish (Color)*What type of phone are you currently using?* Smart phone Flip Phone Other What model Smart phone are you currently using?*How long have you used a Smart phone?*Do you currently have a data plan for your phone?* Yes No Unsure What plan and from what carrier?*Will you be able to continue supporting a plan for a phone if you are provided one for a limited time?* Yes No Unsure What things do you specifically want to do with the phone?*E.g., answer and receive calls, add contacts, download apps, make purchases, etc.Can you set up the phone yourself?* Yes No Unsure Do you have someone who can assist you setting up the phone?* Yes No Unsure What type of training do you need for a new phone?*E.g., in person, one on one, over the phone, etc?Do you need training for a new phone in a language other than English?* Yes No What language for training for your new phone?*Can you travel to Castro Valley for training for a new phone?* Yes No Unsure Do you have a recording device to record phone training lessons?* Yes No Unsure If not, how do you take notes?*Additional information about your iPad requestPlease complete the following information about the iPad you're requesting.iPad model requested*iPad GB Storage*Enter just the number for the GB of storage request, e.g. 128Please state why you need more than 256GB storage for your iPad*iPad Finish (Color)*Have you previously used an iPad?* Yes No If you've previously used an iPad, for how long?*Can you set up the iPad yourself?* Yes No Unsure Do you have someone who can assist you setting up the iPad?* Yes No Unsure What type of training do you need for a new iPad?*E.g., in person, one on one, over the phone, etc?Do you need training for a new iPad in a language other than English?* Yes No What language for training for your new iPad?*Can you travel to Castro Valley for training for a new iPad?* Yes No Unsure Do you have a recording device to record iPad training lessons?* Yes No Unsure If not, how do you take notes?*Additional information about your Apple watch requestPlease complete the following information about the Apple watch you're requestingWhat type of Apple watch are you requesting?* Wifi only Wifi + Cellular What size case are you requesting?* 40mm 44mm What case color are you requesting?*Type and color of wrist band preferred?*Have you previously used an Apple watch?* Yes No If you've previously used an Apple watch, for how long and what version?*Do you currently have an Apple watch?* Yes No Do have an Apple watch data plan?* Yes No What type of data plan do you have for your Apple watch?*Can you set up the Apple watch yourself?* Yes No Unsure Do you have someone who can assist you with setting up the Apple watch?* Yes No Unsure What type of training do you need for a new Apple watch?*E.g., in person, one on one, over the phone, etc?Do you need training for a new Apple watch in a language other than English?* Yes No What language for training for a new Apple watch?*Can you travel to Castro Valley for training for a new Apple watch?* Yes No Unsure Do you have a recording device to record Apple watch training lessons?* Yes No Unsure If not, how do you take notes?*Additional information about your computer requestPlease complete the following information about the computer you're requesting. The type of computer will be determined in a discussion between you and the LVRN computer/technical consultant.Do you currently own a computer? Yes No What type of computer do you own?* Desktop Laptop Other How long have you used a computer?*What is the use for the requested computer?* Personal use Work Both What things do you specifically want to do with the computer?*Do you already own accessories such as a monitor, printer, keyboard, or speakers?*Can you connect the computer components yourself?*Monitor, speaker, mouse, etc. Yes No Unsure Do you have someone who can assist you in connecting the components?* Yes No Unsure Do you have internet?* Yes No Unsure Can you connect the computer to the internet?* Yes No Unsure How many words per minute can you type on the keyboard?*What type of software (Microsoft Excel, Word, etc.) have you used?*Please list each program and the number of years of experience.If you are asking for Microsoft software, what is the latest version you have used?*If you are requesting JAWS software, have you used it before? Yes No Unsure If so, for how long?If you have JAWS, what version do you have?What type of training do you need?*E.g., in person, one on one, over the phone etc?Do you need computer training in a language other than English?* Yes No If so, what language?*Do you have a recording device to record computer training lessons?* Yes No Unsure If not, how do you take notes?*If you live outside of Alameda County, do you have someone who can pick up the computer from Castro Valley?* Yes No Unsure Please explain why the item(s) or service(s) is important to you.*Can you get the item(s) or service(s) somewhere else besides through our grant? Why or why not?*Please list other sources to whom you have applied for this product or service.* In order to qualify, you must provide evidence of low vision or other visual impairment through a form completed to a professional (doctor or counselor, for example) who knows you. Complete the contact information for the person who will be completing your form following. We'll send the form to them via email and they will need to complete the form and return it to us via US Mail. Alternatively, you may download the form and mail it or take it in person to a professional. Download the formProfessional's Name* First Last Professional's Email* Professional's Phone* Preview your application Preview your application answers below to ensure everything is correct. After the preview information, you may sign and submit your application. You'll receive a copy of the application via email. {all_fields:nohidden}SignaturePlease type your full nameGuarantee* I hereby certify that the information provided in this application is accurate to the best of my knowledge.PhoneThis field is for validation purposes and should be left unchanged. Δ
