Name
*
First Name
Last Name
Email
*
Telephone number
*
Address (Street/City/State/Zip)
Date/Place of Birth
Last 4 Digits of Social Security Number
Age
Sex
Ethnicity
Height
Weight
Marital Status
Children? If yes, please include ages
Live With?
Name, Address, and Phone Number of Emergency Contact (or guardian, if minor)
Vision Loss Etiology
Other Disabilities (including mental health issues)
Current Medication
Self-Administered?
If no, please specify assistance needed
Special Diet required (Vegan, religious, diabetic, etc
Have you ever been convicted of a felony?
Have you ever been convicted, imprisoned, on probation or on parole? (Includes felonies, firearms or explosives violations, misdemeanors and all other offenses) If yes, please provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.
Please explain.
Education Completed (Grade, Year)
School for the Blind or Public
Do you:
If yes, do you:
Do you (check all that apply):
Braille Skills?
Current Monthly Income
Do you have an open Vocational Rehabilitation case?
What are your future plans?
Have you reached out to your community for support?
Do you have any additional comments and questions?
Essay
Please answer the following questions fully.
1. What does success and independence mean to you?
2. How can WSB help you reach your goals? (going back, to work, assistive technology, financial literacy, home management)
3. What barriers have you overcome throughout your life? (socio-economic, disability, lack of support, etc.)
4. Have you been denied by Vocational Rehabilitation?
Name & Relationship of person filling out application
Please fill out if the application is filled out by someone other than the applicant.
First Name
Last Name
Relationship of person filling out application
