Welcome to the Vision Nonprofit iPad Assistance Application Form

Application Instructions

At Vision Nonprofit, we are committed to providing technology to individuals with low vision to help them succeed in everyday tasks. This form serves as the official application for assistance. Please read the following instructions carefully before submitting your application.

Eligibility

We primarily support children in grades K-12. If you are outside this age range, you are still welcome to apply; however, assistance may be subject to available funding or special circumstances.

Required Documentation

To complete your application, please attach one of the following supporting documents:

Low Vision Report from Clovernook or another care provider
Letter of Recommendation from a Teacher of the Visually Impaired (TVI)
Letter from an Ophthalmologist confirming diagnosis and needs

School Usage Consideration

We highly recommend that this device be permitted for use in school. Policies vary by school district, so we encourage applicants to check with their school to ensure the device can be used as an educational tool.

Privacy & Document Submission

Due to privacy concerns, we ask that the person submitting the application uploads the required documents on their own behalf.

If you do not hear back within two weeks, please check your spam folder or reach out to eric.hintz@visionnonprofit.org.

Thank you for applying and for your interest in Vision Nonprofit!

*Available while stocks last and subject to receipt of proof of a child’s vision impairment.

Today's Date

YYYY

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Background Information:

1. Briefly describe your or your child’s visual impairment and how it impacts daily life. 2. Are you or your child currently receiving any assistance or support for this visual impairment? (Yes/No) (If yes, please provide details)

Accessibility Needs:

Please answer the following questions to help us better understand how an iPad can support you or your child’s accessibility needs: 1. Explain why you or your child are in need of an iPad for accessibility purposes. 2. Describe how an iPad would assist in overcoming accessibility challenges. 3. What will be the primary use of the device? (e.g., education, accessibility, communication, independent living, etc.)

Childs Date of Birth

YYYY

Certification:

I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that Vision Nonprofit will use this information solely for the purpose of assessing my eligibility for the iPad assistance program.

Digital Signature

Please type your full legal name to used as your signature