Adult Summer Program General Interest From
Your First Name *
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Your Last Name *
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Your Address line 1 *
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Your Address line 2
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Your City *
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Your State *
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Your Zip Code *
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Your email Address
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Best Telephone Number to Reach You *
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Other Telephone Number to Reach You
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Name of Your Primary Emergency Contact *
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eMail Address of Your Primary Emergency Contact
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Best Telephone Number of Your Primary Emergency Contact *
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Other Telephone Number of Your Primary Emergency Contact
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Name of Your Back-Up Emergency Contact
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email Address of Your Back-Up Emergency Contact
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Best Telephone Number of Your Back-Up Emergency Contact
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Other Telephone Number of Your Back-Up Emergency Contact
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What is your date of birth? *
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What is the nature of your blindness or visual impairment and what was the cause? *
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How much vision do you currently have? *
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If you have other vision issues, please explain. These may include light or glare sensitivity, night blindness, field restriction, or other visual problems.
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What is your preferred reading medium? *
What mobility aids do you use: white cane, dog guide, walker, other? *
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Do you work with a representative of the Office for The Blind and Visually Impaired (OBVI)
If yes, what is your representative's name?
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Do you have a counselor from the Division of Vocational Rehabilitation?
If yes, what is your DVR counselor's name?
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Do you use screen reading technology on your computer or telephone?
If yes, please specify.
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Do you use screen magnification software?
If yes, please specify.
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If you have allergies we should be aware of, please list them and tell us how they affect you.
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Your Primary Medical Care Provider's Name
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Provider's Telephone Number
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If you have additional disabilities, please list them and tell us how they affect you.
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Please list all medications you currently use (or should be using) and identify the condition for which each medication has been prescribed:
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Applicant's signature
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Date
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