Online Grant Application Form - Lewis Vision Improvement Foundation.

Thank you for visiting our website. At this time, we are not accepting applications, however, we will keep your application on file for future reference.

Please complete as fully and honestly as possible. This form may be printed.

Information collected is handled in accordance with our Privacy Policy.

If you need someone to support your completion of the application, they must complete Section 2.

Section 1 – About the applicant

Name:*

Prefix First Last

Date of Birth:

Sex:

Address:

Street Address City State / Province / Region ZIP / Postal Code Country

Home Telephone No.:*

Mobile/Work No.:

Email:*

Is the Applicant a Registered Charity? If so, please provide registration number:

Eye Condition:

Please describe the low vision product or service assistance that you wish to obtain. You must include the name and contact information of the low vision product vendor or service provider.*

Have you been tested by the product vendor for product suitability for your low vision condition?

Yes
No

Section 2 – About the supporter

A person (including a parent or guardian) or organization who supports your completion of the application and who knows the applicants circumstances must complete Section 2.

Name

Prefix First Last

Relationship to Applicant:*

Please give a brief description of your relationship to the applicant:*

Work Telephone No.:

Mobile No.:

Email:

Home or Work Address:

Street Address City State / Province / Region ZIP / Postal Code Country

Please briefly describe how LVIF can support the applicant:

Section 3 – Financials

How much is the product or service you wish to obtain?

How much will you be able to personally contribute towards the cost of this product or service?

How much have you successfully raised from fundraising and please describe methods of fundraising have you used?

If you have asked any other grant-giving organization for assistance, please complete information below:

Name of Organization	Contact Number	Support Received	Please provide details of any support approved or date sent if pending

What is the annual household income after taxes?

How many dependents (under the age of 18) are there in the household?

If you are a Student or Employee, please complete Part A and Part B. If you are a Quality of Life applicant, please complete Part B.

PART A: (For completion by Student or Employee applicants)

Current School/College/University/Employment details of applicant:

Institution/Employer Name:

Date Started:

Date of Leaving (if applicable):

Address:

Street Address City State / Province / Region ZIP / Postal Code Country

Student number (if applicable):

Employer reference (if applicable):

PART B: (For completion by Student, Employee and Quality of Life applicants)

To assist us in processing your application, please indicate how low vision has impacted your quality of life and provide three (3) examples of how an LVIF grant may improve your day to day quality of life.

Section 4 – Terms of Grant (To be read and signed by or on behalf of the applicant or supporter applying for a grant on behalf of the applicant). Please check all boxes.

*

I declare that to the best of my knowledge and belief, the answers to the questions contained in this initial application form are correct. I authorize my supporter, if any, to disclose information to LVIF for the purpose of processing my grant application. I declare that I have read LVIF Privacy Policy and consent to the collection, use and disclosure of my personal information by LVIF for the purpose of determining my eligibility for a grant and verifying the information in my application form and other information that I may provide to LVIF.*

*

I declare that, upon acceptance of an LVIF grant, I will endeavour to return to LVIF or the manufacturer of a low-vision product that I may procure from assistance provided from an LVIF grant, any low vision product acquired by me if my personal circumstance can no longer support the usage of the low vision product. This is to ensure the recycling of used low-vision products for future donations at a later date to other low-vision individuals or organizations supporting low-vision individuals. LVIF aims to cultivate a culture of compassion and generosity and find it pertinent that all LVIF applicants align with this view.*

*

If my application is approved by LVIF, I understand that a representative of LVIF may call me to see what difference the LVIF grant has made to me. Please let us know if you’d prefer not to have a follow-up call.*

*

I agree to have the information collected in this application form stored on LVIF’s database.*

*

I have printed out and signed this form.*

What is your preferred method of contact?*

Email
Phone

If you have any questions about your application please contact us:

LVIF Information Resource Team
Lewis Vision Improvement Foundation
102-346 Moodie Dr
Nepean, ON K2H 8G3
t: 613-327-9646
e: info@lewisvisionfoundation.com

Updated: November 2015

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