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Pre-employment Transition Services

Information and Consent Release

Please provide IDB-VR with the following information about the interested student:

Name (First, MI, Last):      

Student Street Address:      

City:       State:       Zip Code:      

Phone Number:       Email:      

School:      

Social Security Number:       Date of Birth:       Gender:      

Are you (Pick one or more):

White Asian Black or African American

American Indian Alaska Native Pacific Islander Native Hawaiian

Are you Hispanic or Latino? Yes No

Select one of the following:

This student has a section 504 accommodation plan based on blindness or vision loss:

This student has an individualized education plan (IEP) based on blindness or vision loss:

This student is an individual with a disability which includes blindness or vision loss and does not have an IEP or 504 plan. ***If checked, please provide documentation from a medical provider.

Consent

I authorize the student listed above to participate in Pre-employment Transition Services. I authorize release of the information disclosed on this form to the Iowa Department for the Blind. I understand that this form will be treated in a confidential manner by IDB-VR.

Student Signature: Date:      

Signature: Date:      

Parent , Guardian or Adult Student

Printed Name: