New Mexico Commission for the Blind
2200 Yale Blvd. SE
Albuquerque, NM 87106
505-841-8844

TECHNOLOGY FOR CHILDREN WHO ARE BLIND AND VISUALLY IMPAIRED

APPLICATION PACKAGE

INSTRUCTIONS

1. Carefully read the Application Form. 

2. If you are the parent, completely answer questions 1 to 13 of the Application Form.

3. If you are the teacher, completely answer questions 14 to 21 of the Application Form.
 
4. The Application Form must be signed by the parent.

5. Ask for help if you have questions.  For help, contact Kelly Burma at 505-841-8844 or 888-513-7958, or by email at kelly.burma@state.nm.us. 

6. Fax the completed Application Form to 505-841-8850, or mail it to:

Commission for the Blind
2200 Yale Blvd. SE
Albuquerque, NM 87106

TECHNOLOGY FOR CHILDREN
APPLICATION FORM
PURPOSE

The Technology for Children program provides assistive technology (technology) to children under the age of 18 who could benefit from such technology because of a visual impairment, but for whom such technology is not available through an Individualized Education Plan, Individualized Plan for Employment, medical insurance, or other similar source. Examples of technology that may be available include Window-Eyes, JAWS, ZoomText, MAGic, optical magnifiers, video magnifiers (CCTVs), Pac Mates, BrailleNotes, and Perkins Braille Writers.
 
PARENT SECTION

(This section is to be completed by the parent, guardian, or power of attorney)

1. Your child’s name:

2. Your name:

3. Your phone number:

4. Your address:

5. You  are the:
___Parent
___Guardian
___Power  of attorney

6. Your Child's school is:

7. Your child's date of birth is: ____/____/____    

8. Name and description of your child’s eye condition:

9. Description of any other medical conditions that your child may have:

10. Technology requested (if possible, identify by name, model, or version): 

11. Describe attempts to obtain the technology from other sources.

12. Describe where the technology will be used, and where it will be stored.

13. The following best describes my ability to afford the requested technology:
___Unable to afford
___Able to afford, but only at great hardship
___Able to afford, but with difficulty
___Able to afford with little or no difficulty. 

SCHOOL SECTION

(The following section is to be completed by the child's teacher, in accord with #17 of the Technology for Children Rules). 

14. Name of teacher:

15. The child's vision is best described by:
___Totally blind (only light perception or no light perception)
___Legally blind (20/200 or worse in better eye)
___Legally blind (less than 20 degree Field)
___Low vision (a severe visual impairment)
___Partially sighted (visual problem resulting in a need for special education)

16. Describe the special education services the child is receiving due to the visual impairment that relate to the technology request:

17. Describe the Child’s reading ability, print and Braille, being sure to include font and reading speed:

18. Describe how the requested technology will complement the educational services that the child is receiving:
19. Provide rationale supporting the requested technology:

20. Describe any similar technology that the child is using in the school:

21. If applicable, describe any technology you believe might more appropriately meet the needs of the child, and explain why:

     
TECHNOLOGY for CHILDREN RULES

I understand and agree that:

1. The technology is the property of the Commission.
2. The technology is on loan unless ownership is transferred.
3. Ownership may be transferred if the Commission determines it is appropriate, which may take place on:
	a. Successful completion of an IPE;
	b. The Commission determines the technology is of nominal monetary value;
	c. After written authorization by the Commission, you repair or upgrade the technology so as to add significant monetary value.
4.  Unless ownership has been transferred, you will not sell, pawn, lend, give away, or discard the technology, and you will reimburse the Commission should you  do so.
5.  Excluding normal wear and tear, you will take reasonable care to protect the technology from damage, loss, or theft, and you will reimburse the Commission for any loss or damage should you not exercise such care.
6. You will file an insurance claim in the event of damage, loss or theft, and transfer the insurance payment to the Commission.
7.  You will not open the case or do anything that would void the warranty. 
8.  You will NOT add Software or allow use unless authorized by the Commission.
9.  You will not repair or service the technology unless authorized by the Commission.
10. The Commission is not obligated to replace, upgrade, or repair the technology.
11. The Commission is not responsible to provide on-going support or training.  
12. If the child is subject to a custody agreement or court order, the technology will transfer with the child unless the Commission determines doing so is inappropriate. Disagreements will be resolved by the Commission, and you will accept such resolution as the final settlement.  
13. You will return the technology should your child no longer be able to benefit by it, or if it is replaced or supplanted.
14. You will return the technology should your child cease to reside in New Mexico.
15. You will accurately and promptly respond should the Commission ask about the technology.
16. You will return the technology should the Commission determine you did not comply with these rules.
17. You authorize the Commission, the New Mexico School for the Blind and Visually Impaired, and your local school to release and discuss educational and other information that may be relevant to your request, including answering questions 14 to 21 of this Application Form.
18. If the technology is denied, you may request a review from the Commission. Your request must be in writing, be received within 15 days of the denial, and describe why you think the decision was wrong.  This review is the final and only appeal available.

Pursuant to 28 U.S.C. Section 1746, I declare under penalty of perjury that my answers to questions 1 through 13 are true and correct, and that I agree to abide by the rules of the Technology for Children program.

Signed on this _____ day of ______________, 20____.

______________________________________
Parent (or Guardian or Power of Attorney)

ACKNOWLEDGEMENT of DEPARTMENT of HEALTH

The Commission gratefully acknowledges the New Mexico Department of Health for providing the financial support that makes this program possible.