First Name
Last Name
Date of birth
Participant's email
Participant's home Address
Address Line 2
City
State
- Select - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
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?
Relationship
Please describe your relationship to the participant if other.
Contact's email
Contact's phone number
Contact's address
Address 2
City
State
- None - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Zip or postal code
Name of TBS/TVI: (if applicable)
TBS/TVI Phone Number
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?
- Select - Eighth Grade High school Freshman High school Sophomore High School Junior High School Senior College Freshman College Sophomore College Junior College Senior Vocational or Technical Training
What is the participant's primary reading medium?
- Select - Large print Braille Electronic format Audio
What is the participant's height?
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
