Name:    

Address:

City:        State: Chose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Mississippi Minnesota Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming  Zip:

Day Phone:   Evening Phone:

Date of Application:

Are you currently registered with MCB? Yes No

Please list potential uses for a computer that would be provided by the Memorial Foundation for the Blind:

Please write list potential uses here:

Please check any items that apply:

Word processing

Scanning Documents

Internet Access

Online Courses

Record Keeping

Education Software

Filling out Online forms

Emailing

Other

Please indicate if any other hardware would be necessary and, if so what type such as printer, scanner, etc.

Please write here if any other hardware would be necessary:

Please write a short narrative explaining what purpose this computer would serve the applicant and how it would be used.

Please write a short narrative explaining here:

MFB CyberSurvey

Do you own a computer? Yes No

What is its operating system?

How much internal (RAM) dose it contain?

How much hard disk storage space dose it have?

What access technology do you use (such as Zoomtex, Jaws, Magic)?

If you use access technology how skillful are you at using it?

Beginner      Average      Advanced

Basic Computer skills assessment

Please answer the questions even if you do not own a computer.

Please rate your computer proficiency using the following scale 1-5 in each of the following skills:

1- Not at all

2- Beginner level

3- Some experience, but in need of practice

4- Reasonable proficient

5- Experienced and very proficient

Use of standard keyboard

Word processing, such as changing fonts, spell-checking, use of text enhancements, formatting, creating

tables    

Creating and accessing e-mails, including attachments

Use of Windows Explorer (my computer) to locate and access computer files

Use of Scanning and recognition software

Working with PDF documents

Filling out Online forms

Addressing and printing of envelopes on a LaserJet or Inkjet printer

Keeping personal records on the computer

Please print and mail this completed application to:
Memorial Foundation for the Blind
799 West Boylston Street
Worcester, MA 01606

Or email completed application by clicking on Submit button