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Adult Program - Enrollment Application

Since 1985, the Louisiana Center for the Blind has provided training and support for persons who are legally blind and their families. Complete and submit the online form below or download a copy of the enrollment application as a Word document.

Name:

Date of Birth:

Gender:

City:

State:

Zip Code:

Email Address:

Telephone Number:

Alternate Contact Information:

Address:

City:

State:

Zip Code:

Educational Background:

   GED

   High School Certificate/Alternative

   Associate Degree

   Masters Degree

   High School Diploma

   Bachelor Degree

Most Recent School Attended:

Employment Background (List last two employers, dates of employment, and position):

Previous training at vocational rehabilitation facility:

Previous training at vocational rehabilitation facility:

   Yes

   No

If yes please list:

Source of Income:

   SSDI

   SSI

   Workmen's Comp

   Self-Support

   Family

   Other

Preferred Medium:

   Braille

   Large Print

   Audio

   Electronic

Vocational Rehab Agency Name:

Counselor Name:

City:

State:

Zip Code:

Email Address:

Telephone Number:

Preferred Date of Enrollment (Pending confirmation from LCB):

Beginning Date:

Ending Date:

Medical Information:

Cause of Blindness:

Visual Acuity: (Send copy of most recent eye exam):

Check if the following apply to you. If any checked then provide medical documentation upon enrollment:

   Diabetes

   Blood Pressure

   Hearing impaired

   Seizure/blackout

   Heart problems

   Strokes

   Hearing aids

   Respiratory problems

   Allergies/asthma

   Kidney problems

   Back problems

   Neuropathy

   Speech disorder

   Orthopedic problems

   Psychological/emotional (depression, behavioral, anxiety, etc); if yes, provide current report from professional

   Learning/cognitive processing; if yes, provide current documentation

   History of alcohol/substance abuse

   Hospitalizations for mental health issues

   Other

Explain if any checked above:

List medications prescribed in last year:

Health Coverage (Provide copies of ID card upon arrival to LCB):

   Medicare

   Medicaid

   Private

Do any areas need immediate attention upon enrollment?::

   Budgeting

   Meal Preparation

   Diabetes Management

   Medical/Health Issues

   Personal Hygiene/Laundry

   Other

Enter any other information that would be helpful in processing this referral (such as adjustment to blindness issues, family situations, training needs, future plans, special diets, etc.):