First Name

Middle Initial:

Last Name

Applicant's Email

Home Phone

Mobile Phone:

Address:

City:

State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands of the U.S Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Date of Birth:

Age at Intake:

If you leave the program early Where will you move?:

Vision Information

How long visually impaired?:

Cause of Visual Impairment:

Visual Acuity:

Visual Field Loss: Central Choose One Yes No

Visual Field Loss: Peripheral Choose One Yes No

Color Blind? Choose One Yes No

Last Opthamalogic Exam

Last Low Vision Exam

Comments About Vision Or Eye Program

What Medications Are You Currently Taking?

Parent/Guardian Information

Name of Parent/Guardian #1

Relationship Choose One Father Mother Relative Guardian Other

Address

Email

Home Phone

Work Phone

Mobile Phone

Name of Parent/Guardian #2 (optional)

Relationship Choose One Father Mother Relative Guardian Other

Address

Email

Home Phone

Work Phone

Mobile Phone

Person To Be Contacted In An
Emergency

Home Phone

Work Phone

Mobile Phone

Education

If In High School,
Expected Graduation Date

Expected To Obtain Choose One Diploma Certificate GED None

If No Longer In High School,
Date Of Completion Or Withdrawal

Higher Education Choose One None Some College Associate's Degree Bachelor's Degree Master's Degree PhD

If Units Only, Approximate
Status Choose One Freshman Sophomore Junior Senior

If You Attended College,
Name of School

City and State of School

Are You Presently In Any
Other Type of School? Choose One Yes No

If Yes, Name of School

Additional Educational History

California Residents

Counselor's Name

Counselor's Phone

Residents From Other States

Name Of Sponsor Or
Sponsoring Agency

Sponsor's Telephone Number

Income

Source of Income

Monthly Income

Are You Your Own Payee? Choose One Yes No

If No, Who Is Your Payee?

Insurance

What Medical Insurance Do
You Have?

Medical Insurance Number

Notes

Referred By