JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Genensky - Foley Magnification Award 2023
Please provide the information requested below. If a Question has a * (asterisk) after it, you must respond to it to save the form.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
1. Applicant’s Personal Information:
Name (First and Last)
*
Your answer
Street Address
*
Your answer
P. O. Box or Apartment
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Phone Number
*
Your answer
Email
*
Your answer
Date of Birth: (mm/dd/yyyy)
*
MM
/
DD
/
YYYY
2 Vision:
How long have you been visually impaired?
*
Your answer
Are you legally blind?
*
Yes
No
What is the cause of your visual impairment?
*
Your answer
What is your degree of vision?
*
Your answer
3. Education:
Are you a High School graduate?
*
Yes
No
Are you currently a student?
*
Yes
No
What is the last grade, degree, or year completed at the time ofsubmission of this application?
*
Your answer
4. Occupation:
Are you currently employed?
*
Yes
No
If you are employed, do you work full or part time?
Full time
Part time
Clear selection
What is your job title?
Your answer
Do you volunteer?
*
Yes
No
If you volunteer, what kind of volunteer work do you do?
Your answer
5. Financial Information:
Do you receive SSI, SSDI, or other government assistance?
*
Yes
No
If you are a student, are you receiving financial aid?
Yes
No
Clear selection
6. Technology
What devices are you currently using to accomplish daily tasks?
Your answer
If you are using magnification devices to perform daily tasks, how do they help you?
Your answer
Have you received help in obtaining devices of any kind in the past? If so, please explain.
Your answer
In a few sentences, please explain how obtaining a magnification device from CCLVI would provide you with technology you may not be able to afford?
*
Your answer
In a few sentences, please explain how a magnification device will enhance your ability to perform daily tasks?
*
Your answer
7. Miscellaneous:
How did you hear about the Genensky Award?
*
Your answer
Are you a member of CCLVI?
*
Yes
No
If not, are you interested in becoming a member or receiving information from us?
Yes
No
Clear selection
Please share any additional information you believe might be helpful for the committee to know in evaluating your application.
*
Your answer
8. If you are under 18, your parent or guardian must fill out the information below.
Name (First and Last)
Your answer
Street Address
Your answer
P.O. Box or Apartment
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Phone Number
Your answer
Email
Your answer
What is your relationship to the applicant?
Your answer
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
