KSBCF BRAILLE WRITER REQUEST

Name:________________________________________ Birth Date: _____ / _____ / _____

Address:___________________________________________________________________

City:_______________________________________State:___________Zip:_____________

Phone:(home)_________________(work)___________________ (cell)_________________

E-mail Address:______________________________________ County: ________________

How long have you been using braille in your everyday activities?_____________________

Please check one: Student ______ (If so, list grade level _____ ) OR Employed _____

Name of school or place of employment and location: ______________________________

_________________________________________________________________

Are you a vocational rehab client? ____ Yes ____ No   If yes, where?_____________________

You must submit the following documents with your application:

  • A current eye exam or verification of legally blind status
  • A letter of recommendation from a teacher, counselor or other professional (if in school)
  • A letter from your rehabilitation counselor (if you are a vocational rehab client)

Please send your application and supporting documents to:

Kentucky School for the Blind Charitable Foundation
214 Haldeman Ave.
Louisville, KY 40206

Fax: (502) 897-3194 | E-mail: contactus@ksbcf.org | Phone: (502) 897-3990

GUIDELINES FOR USE OF PERKINS BRAILLE WRITER

  1. I will assume full responsibility for the braille writer's safe keeping and care.
  2. I will not sell, loan or rent the braille writer to another person.
  3. I will return the braille writer to KSBCF as needed for routine cleaning and maintenance.
  4. I agree to pay for parts that may be needed for repair.
  5. I will not allow anyone except the KSBCF Braille Repair Dept. to do any maintenance or repair work on the braille writer loaned to me.
  6. If I move out of the state of Kentucky, I will return the braille writer to KSBCF. If I move within the state, I will notify KSBCF of my new address.

I hereby agree to comply with the above guidelines:________________________________
                                                                                          (Signature and Date)

Parent/Guardian signature (if applicant is under 20):________________________________
                                                                                          (Signature and Date)

OFFICE USE ONLY:

Date request received: ___________________ Reviewed/Approved by: ______________________

Braille Writer ID#: _________________________ Serial#: _________________________________