NFB EQ Application | National Federation of the Blind

Thank you for your interest in the 2020 NFB EQ program. Please complete the application below. If you have questions, check out our EQ FAQ page, or contact us at 410-659-9314, extension 2418 or at stem@nfb.org.

Student Information

First Name *

Last Name *

Street Address *

Street Address 2 - Optional

City *

State/Province *

Zip Code *

Please make sure your phone number(s) and email address are correct, as we will need accurate information to contact you. The phone number(s) and email listed should be for the applicant (not guardian).

Student's Home Phone Number *

Student's Cell Phone Number *

Student's Email *

Gender *

Birth Date:*

Is the student currently enrolled in school or home schooled in the United States? *

Grant Reporting

The National Federation of the Blind pursues grant funding to support its programs, and some of these grantors ask us to describe the racial/ethnic/socioeconomic backgrounds of our students. In order to improve our program delivery and to respond to these requests, we ask you to answer the following questions.

Ethnicity *

East Asian or Asian Indian

Black, African American, or African

Hispanic, Latino, or Spanish

Native American or Alaska Native

Native Hawaiian or Other Pacific Islander

Other

Prefer Not to Say

White

What is the approximate average annual household income for the student’s primary residence? *

Background Information

Student's Grade for the 2019-2020 School Year *

Please list any science, technology, engineering, or math (STEM) classes the student has taken in high school. *

Please describe the student's academic performance. *

Please list the student's strengths, weaknesses, and any other relevant information. *

What does the student plan to do after high school? What are the student's career goals? *

What is the student's level of interest in the following areas: science, technology, engineering, and math? *

Please describe the student’s technology skills and products that they use. *

Describe the student’s experiences with Braille, if any (e.g., use of a slate and stylus, use of manual or electronic Braille reading, and/or writing devices, reading speed, knowledge of Braille contractions, knowledge of Braille math (Nemeth), experience with Music Braille, etc.). *

How did the student hear about this program? *

Why does the student want to attend the program? *

Does the student belong to an NFB affiliate? If so, which chapter? *

What are the student's hobbies and what extracurricular activities does the student participate in? *

Please describe the student's level of independence and maturity in their travel/mobility skills. *

Has the student participated in any NFB sponsored events? *

Has the student ever attended a day camp or summer program? *

What is the student's reading medium? *

Do you receive the NFB mailing Future Reflections? - Optional

Would you like to receive Future Reflections? - Optional

Is there any other information about the student you would like to share? - Optional

Medical and Vision Information

Please describe the student’s blindness/vision loss. Please include the student’s visual acuity, visual field, and the cause of your student’s blindness/low-vision. Does the student have any other medical conditions or disabilities? *

Does your student have any other special considerations (medical or otherwise) of which we may need to be aware? - Optional

Guardian Information

Guardian First Name *

Guardian Last Name *

Relationship to Student *

Guardian Email *

Guardian Phone Number *