Cane Bank Application

Augusta Georgia Council of the Blind Chapter Project

For Georgia residents only. All required fields are labeled “required.” The trainer name and Street Address 2 are optional. Use Tab and Shift+Tab to navigate. Nothing is sent until you choose Submit Application.

Qualifications

Please read these qualifications to determine whether you are eligible before applying:

Applicants must be legally blind by the national standards.
Applicants must be a Georgia Resident.
Applicants are not eligible for VAMC services as a United States Veteran.
Applicant must be currently participating in, or have completed Certified O/&/M training.
Applicant can only submit one request every 24 months.
If applicants do not qualify to receive a cane from any other organization or program.

Personal Information First name (required) Last name (required) Street address 1 (required) Street Address 2 (optional) City (required) State (Georgia only) zip (required) Phone (required) Email (required)

Form of Communication

Place an X after a choice below that best suits your form of communication. On this website, select one option.

Text Message By Email By Phone

Training Information Where have you received your O/&/M training? (required) What was your O/&/M Trainers Name: (optional, leave blank if you do not remember)

Action Agreement

Submission of this application constitutes your understanding

that you meet the criteria as stated at the top of this form and
you will be responsible for purchasing other accessories beyond the basic cost of $60.00 for the Cane, the cane tip, taxes and shipping preapproved by this program. For example, if you are requesting a specific color, grip or cane quality, it might bring your total cost over $60.00 in which you will be responsible for the difference at time of purchase.

I understand and agree to the Action Agreement. (required)

Application information will be sent by email to the five Cane Bank program contacts. A separate, brief acknowledgment email will be sent to the email address you enter. The acknowledgment does not include your application answers. Do not add information beyond the requested fields.

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