RSVP 1

Welcome to the Vision Nonprofit iPad Assistance Application Form

At Vision Nonprofit, we understand the challenges individuals with low vision face in accessing technology for everyday tasks. We're committed to providing support where it's needed most. Before you begin filling out this form, please read the following instructions carefully. Your privacy and dignity are our top priorities, and all information provided will be treated with the utmost confidentiality. Thank you for considering Vision Nonprofit for your accessibility needs.

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

Accessibility Needs:

1. Explain why you are in need of an iPad for accessibility purposes: 2. Describe how an iPad would assist you in overcoming accessibility challenges:

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