Adaptive Technology Scholarship Application McBurney Disability Resource Center Form Use and Accessibility: This document is a fillable Microsoft Word form and the data you enter can be saved as part of the document Please keep an electronic copy as you will likely be asked for an electronic copy of your application The majority of this application form is a Word form with fillable form fields The Protect Document function has been turned on in this Word document to make the form fields active and prevent users from editing text outside the form fields You can use the key and + (or the mouse) to move between the fields and the space-bar to mark check boxes Unfortunately, spell checking is not available in fillable form fields Therefore, you may want to compose longer responses in a separate document and then copy them into the form fields Form fields are labeled with text to identify them when using screen reading software However, it may still be necessary to read the text around the form fields to fully understand the context of the question The equipment table in the “Equipment Requested” section is not a fillable form and is not protected to allow you flexibility in adding or deleting rows from the table If you encounter difficulties in accessing or filling out this form, please contact us Eligibility Criteria: Deadline: Applications are due by 4:30pm on the date listed on the scholarship page of mcburney.wisc.edu/scholarships/ All materials, including the letter of support, financial aid/need information, and VR letter (if applicable) must be submitted by this deadline The review committee may choose to review late applications, subject to available funding and after decisions are made for on-time applications Current undergraduate or graduate/professional student: Must be a current UW-Madison undergraduate or graduate/professional student with a permanent disability who is approved for services through McBurney Accommodations approval and planned enrollment at UWMadison must extend for at least one semester beyond the current semester University Special and Guest students are not eligible for this scholarship Financial Need: Must have a demonstrated financial need, as verified by the Financial Aid Office If the student has not applied for financial aid, he or she should submit the Financial Need Addendum, which is available as a separate document on the McBurney scholarship web page Financial need also helps determine if all or part of the scholarship request is funded Vocational Rehabilitation: An applicant who is a Vocational Rehabilitation (VR) client must provide a letter from their VR counselor stating that VR will not fund the requested equipment and providing a legitimate reason for the denial Available Technology: Preference will be given to applicants who are unable to use technology that is available for use in campus libraries and campus InfoLabs, or that is available for loan from McBurney Appropriate Technology: The technology being requested must be consistent with the approved accommodation and the student’s disability (e.g., being approved for Alternative i McBurney Adaptive Technology Scholarship Formats/Document Conversion and having a print related disability if requesting scan and read software) Number of Awards and Amounts: The number and amount of scholarships awarded varies and is dependent upon available funding Donor Thank You Letters: Students who receive a scholarship are expected to send a thank you letter to the donor within one month of receiving an award in order to maintain eligibility for future scholarships and to acknowledge the generosity of the donor(s) ii McBurney Adaptive Technology Scholarship Applicant Instructions & Checklist Eligibility Criteria: Verify that you meet the Eligibility Criteria listed above Read eligibility criteria Letter of Support: Applicant must submit a letter of support from his or her McBurney Accommodation Specialist related to the technology’s effectiveness and/or appropriateness as an accommodation Requested letter of support from accommodation specialist Scholarship application: Electronically complete the application form attached to these instructions Sign a completed printed copied Completed/signed application form Financial need information: If you have not applied for financial aid for the current academic year, complete & submit the Financial Need Addendum to the Financial Aid Office Submitted completed Financial Need Addendum (if appropriate) VR letter: Obtain VR letter, if appropriate See #4 in Eligibility Requirements above Obtained VR letter (if appropriate) Copies: Keep a full set of electronic and print copies of all documents for your records Submit application packet: Submit your signed scholarship application form, letter of support, and VR (if appropriate) to the McBurney Disability Resource Center by dropping off, mailing, or faxing (Note: We likely will request an electronic copy of your application materials to increase accessibility for scholarship reviewers.) McBurney Contact Info McBurney Disability Resource Center 702 W Johnson St, Suite 2104 Madison, WI 53715 (phone) 608-263-2741 (texting) 608-225-7956 (fax) 608-265-2998 (email) mcburney@studentlife.wisc.edu (web) mcburney.wisc.edu iii McBurney Adaptive Technology Scholarship Saved electronic copies Made print copies Submitted completed application packet by deadline, including: • Signed application form • Letter of support • VR letter (if appropriate) • Financial Need Addendum (to Financial Aid Office if appropriate) Office Use Only: Date Received: _ Received By: Adaptive Technology Scholarship Application McBurney Disability Resource Center I Applicant Information Applicant’s Name: Student ID #: Address 1: Address 2: City: , State: , Zip or Postal Code: Country: Phone Number: Email: Are you a U.S resident? Yes No (Note: If “No,” additional information will be needed to process scholarship checks.) Current Academic Level: High School Senior Admitted to UW-Madison Freshman Professional or Sophomore Graduate Student Junior Senior (Note: University Special and Guest students are not eligible for this scholarship.) Degree Goal: B.A./B.S Major Area(s) of Study: M.A./M.S Ph.D Other: Cumulative G.P.A.: Full/Part-time Status: Full-time Student Part-time Student (For more info see “Full-Time/Part-Time Status” definition on the Registrar’s website) Expected Graduation Date: Briefly describe your disability: Briefly explain the impact(s) of your disability, particularly related to your academics and role as a student: McBurney Adaptive Technology Scholarship II Equipment Requested In the table below, please list each piece of hardware, software, or related AT service you are requesting in order from highest to lowest priority, and include price information for each item Note that depending on financial need, all or part of the request for funding may be considered Equipment or Service (brand, product, version) e.g Victor ReaderSoft Version 2.0 for Windows Brief Description and Use/Justification e.g Read RFB&D books on my Windows computer Price (including shipping, tax) e.g $89 Total Amount Requested: $ Additional Equipment Information: Please summarize and/or attach additional information about the equipment requested that may support or strengthen your request Such information might include product specifications, product information from websites, vendor quotes, evaluations showing improvement in your performance, compatibility information, improved features, etc You may type this information below or attach it as additional pages McBurney Adaptive Technology Scholarship III Explanation of Need Please respond to the following questions in a specific and thorough, yet concise manner There is not a minimum or maximum length, and the space provided is not intended to indicate the expected length of responses Feel free to add additional space or sheets as needed to answer the questions appropriately Use and Benefits of the Technology Classify the type of experience you have using the technology you are requesting? (check all that apply) Saw a demonstration (in person or online) Researched available products and selected this as a best option Used for trial period (demo software, loan, etc.) Received professional evaluation that recommended the product(s) Seeking upgrade after using previous version successfully Other: Expand on and/or clarify any previous experiences using the equipment being requested and/or related equipment Describe how you anticipate using this technology, particularly as it relates to your academic studies/ goals, internships/practicums, and other academic/employment related pursuits In the context of your disability and the challenges it creates for you in academic and employment situations, describe why you expect the equipment you are requesting will improve your functional capabilities, decrease access barriers, etc Is the equipment available for use in UW-Madison libraries, campus InfoLabs, or departments, or is it available on loan from McBurney? Yes No If yes, please explain any special circumstances that make it difficult for you to use the technology in libraries, labs, or on loan (e.g., distractibility issues, fatigue issues, extensive use of reading materials available only in PDF format, child care responsibilities, etc.) McBurney Adaptive Technology Scholarship Financial Need Have you applied for financial aid for the current academic year? Yes No (If no, please make sure to submit the Financial Need Addendum to the Financial Aid Office McBurney Center will contact the Financial Aid Office to ascertain financial need based on summary information.) Have you previously received a McBurney Scholarship or a McBurney AT Scholarship? Yes No If yes, please list approximate dates and amounts Are you currently a client of Vocational Rehabilitation (VR) Services? Yes No (If yes, please attach the letter from your VR counselor stating the reasons why they have denied your request to fund the equipment.) Please explain any financial issues or special circumstances that prevent you from purchasing your own equipment Would you be able to purchase the equipment you are requesting if you received partial funded by this scholarship? Yes No Support, Training, and Compatibility What is your plan for getting training on the use of this technology? What is your plan for getting technical support on the use of this technology? If the equipment requested above is used on a computer: Have you checked that your computer is compatible with the hardware and/or software that you are requesting? Yes No What operating system does your computer have? Windows Mac Other: McBurney Adaptive Technology Scholarship What type of computer you have? laptop or desktop computer? By applying for this McBurney Adaptive Technology Scholarship, I give permission for the UWMadison Financial Aid Office to provide the McBurney Disability Resource Center with information pertaining to my level of financial need as a part of determining my eligibility for this scholarship This information may be obtained from either my Financial Aid Application or the “Financial Need Addendum” form I attest that the information in this application is true and accurate to the best of my knowledge Name (Printed): Applicant Signature: Date: McBurney Adaptive Technology Scholarship Form Last Updated: 5/24/2019 eyk1667324397.doc (for McBurney website) McBurney Adaptive Technology Scholarship