NOAH iPad and Technology Assistance Program Application

Please note: This grant program provides full funding for devices valued at $500 or less, and partial funding for devices exceeding $500.

Questions? Contact technology@albinism.org.

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* 1. Did you participate live or review the recording of NOAH's Technology Assistance Demo Webinar? NOAH strongly recommends reviewing this resource prior to application.

Yes

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* 2. The person completing this application is:

Applicant

Applicant's parent/guardian

Applicant's vision professional (eye doctor, TVI, COMS, etc.)

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* 3. Name of individual, parent and/or vision professional filling out the application

Name

Email Address

Phone Number

While a vision professional's recommendation is not required, all applicants are strongly encouraged to include one, and applications supported by a recommendation will be given preference. Recommendations should be submitted at https://www.surveymonkey.com/r/NOAH-Ipad-recommendation by the application deadline. Questions should be directed to technology@albinism.org.

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* 4. Applicant Contact Information

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 5. Are you in NOAH's contact database?

Yes

Not sure

Please add me to NOAH's contact database using the information supplied on this form.

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* 6. Applicant Date of Birth

Select applicant's date of birth from the calendar.

Date

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* 7. Does the applicant have albinism?

Yes