RISE Application | National Federation of the Blind of Virginia

First Name

Last Name

Date of birth

Participant's email

Participant's phone number: (including area code)

Use only digits, no dashes.

Participant's home Address

Address Line 2

City

State

Zip or postal code

What is the medically diagnosed condition causing the participant's loss of or low vision?

Does the participant have additional disabilities, in addition to vision loss?

Parent or guardian full name

If participant is above the age of 18, please list emergency contact information.

Please describe your relationship to the participant if other.

Contact's email

Contact's phone number

Name of TBS/TVI: (if applicable)

Name of Vocational Rehabilitation Counselor

Name of Orientation and Mobility Instructor: (if applicable)

In which school is the participant enrolled?

What year of school is the participant currently in?

What is the participant's primary reading medium?

Does the participant use a cane, guide dog, or neither?

Does the participant have any dietary restrictions or allergies? If so, please describe in detail

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