VR Application Worksheet
| First Name | |
|---|---|
| Last Name | |
| Date of Birth | |
| Student with a Disability? | |
| If yes, IEP or 504? | |
| Social Security Number | |
| Are you your own guardian? | |
| Primary Email | |
| Secondary Email | |
| Phone Number | |
| Secondary Number | |
| Preferred Method of Contact | |
| Preferred Media (Electronic, large print, Braille) | |
| Other Contact Information | |
| Marital Status | Divorced Married Never Married Separated Widowed |
| Citizenship | Naturalized U.S. Citizen U.S. Citizen or National by Birth in the U.S. or U.S. Territory/Commonwealth U.S. Citizen or Nation by Birth, Born to U.S. Parents in a Foreign Country Not a U.S. Citizen |
| Ethnicity | Did Not Self Identify Hispanic or Latino Not Hispanic or Latino |
| Veteran? | |
| If yes, do you receive veteran benefits? | |
| Gender | Male Female Did not identify |
| Race-choose all that apply | American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Did not self-identify his/her race |
| Languages-choose all that apply | English Spanish American Sign Language (ASL) French German Italian Japanese Portuguese Vietnamese Greek Other: |
| Mailing Address | Street: City: State: County: |
| Physical Address (if different) | Street: City: State: County: |
| Registered to Vote? | |
| State issued driver’s license? | |
| State issued ID? |
Program Information
| Source of referral | |
|---|---|
| Living arrangement | |
| What is your disability | |
| What is the cause of your disability? | |
| SSI due to blindness? | |
| SSDI due to blindness? | |
| Public support | 0 - Individual does not receive public support 1 - Individual receives Social Security Disability Insurance (SSDI) 2 - Individual receives Supplemental Security Income (SSI) 3 - Individual receives Temporary Assistance for Needy Families (TANF) 4 - Individual receives other public support from another source |
| Medical insurance coverage at application | 0 - Applicant does not have medical insurance coverage 1 - Applicant has Medicaid 2 - Applicant has Medicare 3 - Applicant is receiving benefits through the State or Federal Affordable Care Act Exchange at the time of application 4 - Applicant has public insurance outside of Medicare, Medicaid, or the Affordable Care Act exchange 5 - Applicant has private insurance through employer 6 - Applicant is not eligible for private insurance through a current employer, but will be eligible for private insurance after a certain period of employment 7 - Applicant has private insurance through other means |
Educational Information: Highest level of education Date of graduation |
|
|---|---|
| Social/Recreational | |
| Work History/Vocational Goals: | |
| Attitude regarding blindness |