Grant Application

Grant Application Form

South Central Kentucky Council of the Blind

With the submission of the SCKCB Grant Application Form, you are acknowledging that you have read the SCKCB Grant Guidelines and fully comply with and agree to the conditions set forth in those guidelines.

Grant applicants will be notified, in writing (either hard copy or electronically), of the decision within ten days following the Quarterly meeting of the Grant Oversight Committee in which the decision about your application is rendered.

An individual seeking matching funds is not eligible if they have already purchased the piece of equipment prior to or at the time of applying for a SCKCB Grant, i.e. any reimbursement for devices already purchased is not allowed.

Please answer the following questions (* indicates a required entry):

Application Date: (*)
Name of grant beneficiary: (*)
Beneficiary First Name:
Beneficiary Last Name:
Mailing Address:
Beneficiary Address Line 1:
Beneficiary Address Line 2:
Beneficiary City:
Beneficiary State:
Beneficiary Zip Code:
Beneficiary County of Residence
Phone Number (including area code): (*)
Email Address:
Is the beneficiary of the requested grant legally blind? (*)	Beneficiary is legally blind
	Beneficiary is not legally blind
If the beneficiary is under the legal age of 21, Name of parent or guardian
Parent/Guardian First Name:
Parent/Guardian Last Name:
If the beneficiary is under the legal age of 21, Address of parent or legal guardian:
Parent/Guardian Address Line 1:
Parent/Guardian Address Line 2:
Parent/Guardian City:
Parent/Guardian State:
Parent/Guardian Zip Code:
Requested grant amount: (*)
Purpose of the grant: (*)
Please provide a detailed description of the item(s), cost and the name of the company from which the equipment is to be purchased. Attach a brochure or catalog copy if available.
Upload attached brochure/catalog information:	Acceptable file types are PDF (.pdf) and Microsoft Word (.doc and .docx) files.
Please describe how the attainment of the device for which the grant funds will be used will benefit the user:
Since the SCKCB grant provides up to a maximum of 50% (75% for SCKCB members) of the purchase cost of the device for which the funds are intended, from what source will the remaining 50% (25%) come? (Please provide evidence of these matching funds)
Upload supporting document:	Acceptable file types are PDF (.pdf) and Microsoft Word (.doc and .docx) files
Electronic Signature of Applicant (if of legal age) or legal guardian: (*)
Signature Date: (*)