Michigan School for the Blind Trust Fund Enrichment Program/Event Scholarship Application Packet The Stanley Herman Trust has been designated to support students who are blind/visually impaired (BVI) and meet the eligibility criteria. The funds are provided to support enrichment of school programs and services, trainings, recreational and social activities for students. Required Information The following information MUST be sent to Michigan Department of Education-Low Incidence Outreach (MDE-LIO) 15 days prior to the event. You will be notified of approval of a scholarship request within five business days. Enrichment Program/Event Scholarship Application Form, completed and signed. Enrichment Program/Event Scholarship Certificate of Eligibility Form, completed and signed by a certifying authority. A copy of the program/event registration form (flyer, newsletter, etc., announcing event). Documentation with proof of financial need (copy of current Bridge Card OR qualification for free and reduced meals; if your child does not qualify for either of the above, your application will not be accepted). Parents are responsible for paying all event fees as well as registering themselves/their child for the program or event; reimbursement of the originally approved amount will be given after all required documentation is received by MDE-LIO. Families will be notified by letter whether their scholarship application is approved or denied. The following information MUST be sent to MDE-LIO no later than 30 days after the event to receive reimbursement: Program/Event Scholarship Attendance Confirmation Form, completed and signed after attending the enrichment program/event by the program coordinator. Scholarship Application Checklist 1 Revised on 11.8.2017
Michigan School for the Blind Trust Fund Enrichment Program/Event Scholarship Application Form The following form needs to be completed by the parent(s) of the child attending the event. If you have more than one child attending an event, you will need to fill out a separate application for each child attending. ONLY children that qualify for the scholarship will be considered. Read through the entire application packet carefully, and submit all pages. Please print or type in the requested information below: Today s Amount Requested (cannot exceed $250): If you are requesting mileage reimbursement, please see the Scholarship and Travel Reimbursement Information Sheet on page 8 of this packet. MDE-LIO will only reimburse up to 100 miles at the current approved state rate of $.535 per mile. Are you applying for reimbursement of mileage expenses to and from the event? Yes No Applicant (Child) Name: Date of Birth: Parent/Legal Guardian: Phone Number: Email: Address: City: State: Zip: School District: Teacher/TCVI: Name of Enrichment Program or Event: Date(s) of Enrichment Program or Event: Scholarship Application Form 2 Revised on 11.8.2017
How will this activity benefit or enrich the child s/student s life? OR list 3-5 goals and objectives for this activity (please respond in 3-5 sentences). By submitting this application, I give permission for my child to attend the above enrichment program/ event. The undersigned hereby releases the State of Michigan and all its agencies and departments from liability for any injury and/or damage occurring during attendance at the above enrichment program/event. Parent/Legal Guardian Signature: Scholarship Application Form 3 Revised on 11.8.2017
Michigan School for the Blind Trust Fund Scholarship Certificate of Eligibility Form In order for an applicant to be considered eligible for a scholarship, a parent/legal guardian needs to verify that their child has a visual impairment as demonstrated by the completion of this form. If this form is not filled out and attached with the Enrichment Program/Event Scholarship Application Form, your application will not be considered for scholarship reimbursement. The following Certificate of Eligibility must be completed and signed by a competent authority OTHER than the applicant s immediate family. In cases of blindness or visual impairment, competent authority is defined to include an ophthalmologist, optometrist, teacher of students of the visually impaired, or a Certified Orientation and Mobility Specialist. To Be Completed By A Certifying Authority Certifying Authority Name: Title and Occupation: Phone Number: Email: Address: City: State: Zip: Applicant (Child) Name: I certify that the applicant named above meets the definition of visually impaired as specified in R 340.1708 or R 340.1717. Certifying Authority Signature Certificate of Eligibility Form 4 Revised on 11.8.2017
Return the completed Enrichment Program/Event Scholarship Form along with the completed Certificate of Eligibility Form to: Michigan Department of Education-Low Incidence Outreach Attn: Melissa Salyer 702 West Kalamazoo Street -8242 Fax: 517-335-1632 If you have questions, contact the Michigan Department of Education-Low Incidence Outreach at: Toll Free: 888-760-2206 Direct: 517-241-9844 Email: salyerm1@michigan.gov MDE-LIO Office Use ONLY. Do not write below this line. Approved Denied Other: Signature: Signature: Certificate of Eligibility Form 5 Revised on 11.8.2017
Enrichment Program/Event Attendance Confirmation Form This form is to be filled out after the event and needs to be submitted along with all supporting documentation, including itemized receipts. If travel reimbursement is applicable please see the Scholarship and Travel Reimbursement Information Sheet on page 8 of this packet. Send this finished form to MDE-LIO within 30 days after the event. Please type or print out the following information: Applicant (Child) Name: Name of Program: Date(s): The original agreed amount to be reimbursed: By submitting this attendance confirmation, I certify that my child attended the above enrichment program/event. The undersigned hereby releases the State of Michigan and all its agencies and departments from liability for any injury and/or damage occurring during attendance at the above enrichment program/event. Parent/Guardian Signature: To Be Completed By The Program Coordinator The program coordinator is the individual who coordinated the event, or a person from the event, other than a family member of the applicant, who can attest to the participation of the applicant. I understand that when a child is issued this scholarship from the Michigan School for the Blind Trust Fund (MSBTF), an award letter is sent to the child s family. A maximum of $250 may be awarded per child/event. The family of the child is responsible for paying all registration fees, and they will be reimbursed for only the approved specified amount on the original scholarship agreement. Note: All scholarship applications MUST be received and approved by the MSBTF PRIOR to the date of the enrichment event the applicant wishes to attend. Enrichment Program/Event: Address: City: State: Zip: Attendance Confirmation Form 6 Revised on 11.8.2017
Federal Tax ID # (if it applies): Program Coordinator Name: Title and Occupation: Phone Number: Email: I verify that the applicant named above attended the above enrichment program/event. Program Coordinator Signature: Return completed form to: Michigan Department of Education-Low Incidence Outreach Attn: Melissa Salyer 702 West Kalamazoo Street -8242 Fax: 517-335-1632 A t t e n d a n c e C o n fi r m a t i o n Fo r m 7 Revised on 11.8.2017
Michigan School for the Blind Trust Fund Scholarship and Travel Reimbursement Information Sheet The State of Michigan has changed some of its procedures. All potential vendors/presenters/customers will receive their payments via Electronic Funds Transfer (EFT). EFT Registration Instructions: Everyone who does business with the State of Michigan needs to do the following: 1. Register as a State Vendor by creating an account through the SIGMA VSS website: (https://sigma.michigan.gov/webapp/prdvss2x1/altselfservice). 2. Follow the online instructions to complete the registration process. You can view the SIGMA VSS User Guide for instructions to complete your registration. 3. If you have any problems, call the help desk at 888-734-9749 or by emailing SIGMA-Vendor@Michigan.gov. The people there will be able to assist you. If you stated in your scholarship application that you would like to receive reimbursement for travel expenses, the Non-State Employee Travel Voucher form must be completed. This form must be completed, signed, and returned along with complete Google Maps/MapQuest directions (to and from the event) including the map, itemized receipts, and the Scholarship Event Attendance Confirmation Form. MDE-LIO will only reimburse up to 100 miles at the current approved state rate of $.535 per mile. To receive a copy of the Non-State Employee Travel Voucher form please contact Melissa Salyer at SalyerM1@michigan.gov. When submitting the signed travel form, please attach all parking receipts and toll/cab receipts. Travel Reimbursement In f ormation Sheet 8 Revised on 11.8.2017