Personal Information

Name:

Gender:

Address:

City:

State:

ZIP Code:

Email Address:

Telephone Number:

Alternate Contact Name:

Alternate Contact Address:

Alternate Contact City:

Alternate Contact State:

Alternate Contact ZIP Code:

Alternate Contact's Telephone Number:

Educational Information

Educational Background:

Most Recent School Attended:

Date of Most Recent School  Attendance:

Employment Background

Most recent Employer:

Most recent Employment Dates:

Most recent Employment Position:

Previous Employer:

Previous Employment Dates:

Previous Employment Position:

Miscellaneous Information

Vocational Goals:

Source of Income:

Preferred Medium:

Vocational Rehabilitation Agency

Agency Name:

Counselor Name:

Counselor Phone Number:

Counselor Address:

Counselor E-mail Address:

Preferred date of enrollment:

(Pending confirmation from LCB)

Medical Information

Medial Issues:

Additional Information Regarding Medical Issues:

Are any medications taken daily?:

(Please list & indicate whether
you self-administer)

Health Coverage:

(example: Medicare, Medicaid, BlueCross, etc.)

Additional Information

Do any areas need immediate attention upon enrollment?

Please 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.)