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Apply Online: Anne Mac Rae Technology Scheme

To apply, please fill in the form below.

You must answer every question, especially the question about current computer ownership
(ie only people who do not already have computer equipment can apply).

A computer and webcam costs $300.00. You must pay $100.00 towards the cost. Please post a cheque payable to "The Deaf Society of New South Wales" to PO Box 1060, Parramatta NSW 2124
or pay at your nearest Deaf Society office during business hours. For office locations, click here.
 
Application Form - please fill out the online form below
Q1. What is your name?
Title:
Mr Mrs Ms Miss Other:
First Name:
Last Name:
 
Q2. What is your date of birth?
 
Day:   Month:   Year:  
 
Q3. What is your gender?
 
Male   Female
 
Q4. Where do you live?
Street:
Town/Suburb:
  State:   Postcode:
 
Q5. How do we contact you?
Home:
  TTY   Voice   Both
Work:
  TTY   Voice   Both
Mobile/SMS:
  SMS   Voice   Both
Fax::
      Home   Work

Email Address:
Q6. If we cannot reach you who else can we contact?
Parent Child Brother / Sister Friend
ILSP Worker The Deaf Society Other
 
Q7. What is this person's name and their contact details?
Title:
Mr Mrs Ms Miss Other:
First Name:
Last Name:
Phone:
  TTY   SMS   Voice
Q8. Are you Deaf / hard of hearing?
 
Yes No
 
Please give a copy of your audiogram / written evidence of your hearing loss to the Deaf Society.
(Applicants must be deaf or hard of hearing with a hearing loss of 55db or more in the good ear [World Federation of the Deaf definition])
 
Q9. Do you have a disability?
No (If NO, please go to question 10)
Yes If YES, what is your disability?
 
Blind / Visual Impairment
Intellectual Disability
Physical Disability (eg Cerebral Palsy)
Mental Illness
Other - please specify:
 
Q10. How will the computer equipment help you?
 
 
Q11. Do you already have a computer at home?
  Yes No
 
We need to know a few things about how your disabilities affect the way you use a computer.
Q12. Please answer all of the following questions if you can:
  Your Hearing    
  Can you hear the warning sounds made by a computer? Yes No
  Do you need visual warnings displayed on the screen? Yes No
       
  Your Vision    
  Do you need to use screen colours that are bright and high contrast? Yes No
  Do you need to have large letters and icons on the screen? Yes No
       
  Your Hand Movement and Control    
  Can you use a keyboard? Yes No
  Can you use a computer mouse? Yes No
 
Q13. Can you use a computer already?
  Have you used a computer before? Yes No
  Do you need computer training? Yes No
 
Q14. Do you also want any of these?
  A modem (for the internet) Yes No
  A webcam Yes No
Q15. Where do you want the computer equipment delivered?
Please deliver my computer equipment to:
Title:
Mr Mrs Ms Miss Other:
First Name:
Last Name:
Street:
Town/Suburb:
  State:   Postcode:
Phone:
  TTY   SMS   Voice
 
     
  NOTE:
You will need a desk that is at least 90cm x 70cm, a four socket power board and access to the power point.		  
     
 
Q16. Will you need someone to help you set up the computer when it is delivered?
  Yes No
 
The total cost of this computer equipment is $300.
The Deaf Society will pay $200 towards this cost and the applicant is required to pay the remaining $100.
Q17. Have you paid your $100.00 to the Deaf Society?
  Yes (If YES, to to Applicant Agreement below)
  No If NO, when and how will you pay the Deaf Society?
   
 
Applicant Agreement

Only a person over the age of 18 years and legally able may enter into a contract to hire a computer from The Deaf Society of New South Wales and Technical Aid to the Disabled NSW.

   
If I am successful in this application, I give permission for the installation of a computer and other equipment I have asked for. Yes No
     
I understand that I have to pay for internet connection and ongoing associated fees and charges myself. Yes No
     
I understand that I have to pay for print cartridges and paper myself. Yes No
     
I confirm that all the information I have supplied above is true. Yes No
 
Please type your full name:
Date: Day:   Month:   Year: