Street Address:

City:      State:      Zip:

Home Phone:       Email:

Parent(s) or Guardian(s):

Street Address (if different from above):

City:      State:      Zip:

Home Phone:      Work Phone:

Emergency contact (other than parent(s) or guardian(s):

Emergency contact phone number:

GENERAL INFORMATION

Gender (m/f):      Age:       Date of Birth:

Grade/year of school completed:

Name of school :

Vocational Goal:

Cause of blindness:

Name of applicant's vision teacher (if applicable):

Name of applicant's vocational rehabilitation counselor:

BLINDNESS SKILLS TRAINING

Do you read braille (y/n)?

If yes, contracted or uncontracted?

Words per minute reading:

What do you use to write braille? (slate & stylus, brailler, note taker)

Do you use a cane (y/n)?

Have you had any computer training? If yes, using which program for accessibility (i.e., JAWS, Window-Eyes, ZoomText, etc.)?

Hobbies/interests:

MEDICAL INFORMATION

Do you take any medications on a regular basis? (y/n) If yes, please fill in the fields below:

Reason for medication:

Do you administer the medication independently?

Additional comments:

Reason for medication:

Do you administer the medication independently?

Additional comments:

Reason for medication:

Do you administer the medication independently?

Additional comments:

If there are additional medications, please attach a separate sheet.

Do you have any allergies? If yes, please explain:

Do you have any dietary restrictions? If yes, please explain:

Name of insurance provider:

Policy number:

Please list any other questions or concerns that you may have, or information that you would like us to have:

Signature of Applicant: __________________________ Date: __________

Signature of Parent or Legal Guardian: __________________________ Date: __________
(if applicant is under 18 years of age)

TAKE A TOUR** We invite you to take a tour of our facilities and learn more about our program. Please call (612) 872-0100, or our toll-free number 1-800-597-9558, to arrange a visit.