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Barbara Fierst Memorial Technology Grant

Mountain State Council of the Blind
Barbara Fierst Memorial Technology Grant
Application Form for Assistive Devices

Assistive devices, not to exceed $500 may be provided by MSCB to eligible applicants. Only one application per individual may be submitted annually. Applicants must be at least 18 years of age and a resident of West Virginia.

Please complete the following online application form, or download application form and return to:

Donna Brown, Awards Committee Chair
Mountain State Council of the Blind
PO. Box 188
Romney, WV 26757

This organization guarantees that your personal information will not be shared with any persons or parties outside the Awards Committee. Decisions of the Awards Committee are final.

A recipient of this grant is requested to pay one year MSCB membership dues in the amount of $10.

Online Application Form

1 Start 2 Complete

ONLINE Barbara Fierst Memorial Technology Grant Application

Personal Information

First and Last name *

Street address *

City/State/Zip *

Primary Phone *

Mobile Phone

Email Address *

Re-type Email *

Visual Diagnosis: (doctor's report not required)

Visual Acuity if available left eye

Visual Acuity if available right eye

Visual Field if available left eye

Visual Field if available right eye

Employer if applicable:

Presently in school? *

Yes

Name of school if applicable:

Technology Device Information

Device requested: *

List any vendors contacted, cost of device and vendor's contact information:

Write a short statement outlining how you plan to use this device. Upload a page below if needed.

Upload statement of how you plan to use this device. Hit "Browse" to select your file, then "Upload".

Files must be less than 2 MB.
Allowed file types: txt rtf pdf doc docx.

Have you investigated other funding resources? *

Yes

If yes, please specify.

Should the device no longer be needed, do you agree to return the device to MSCB for continued distribution? *

I agree. This constitutes your signature of agreement.

Leave this field blank

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Barbara Fierst Memorial Technology Grant

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