Date of Birth *
Date of Birth
Gender *
Address *
Address
Home Phone
Home Phone
Cell Phone *
Cell Phone
Alternate Contact *
Alternate Contact
Alternate Contact Address *
Alternate Contact Address
Educational Background *
Previous training at vocational rehabilitation facility? *
Have you ever been convicted of a criminal offense (felony or misdemeanor)? *
Source of Income: *
Preferred Reading Medium: *
Counselor's Phone
Counselor's Phone
Counselor Adress *
Counselor Adress
Preferred date of enrollment (Pending confirmation from LCB): *
Preferred date of enrollment (Pending confirmation from LCB):
Preferred Ending Date of Enrollment: *
Preferred Ending Date of Enrollment:
Cause of Blindness
Check if the following apply to you. If any checked then provide medical documentation upon enrollment: *
List medications prescribed in last year; indicate those currently taking; please indicate if you can self-administer these medications:
Health Coverage (Provide copies of ID card upon arrival to LCB): *
Needs
Do any areas need immediate attention upon enrollment? Please check any or all that apply.
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.):

To find out more about the LCB Adult Training Program, click any of the links below.