Future Reflections Fall, 2003
NAME: Last ____________________ First ________________ MI _______
ADDRESS: ____________________________________________________
CITY: _________________ STATE: ____________ ZIP: _____________
HOME PHONE ( ) _______________ WORK PHONE ( )______________
I am registered with a state or private vocational rehabilitation agency for the blind.
[
] Yes [ ] No If yes, please give name: _____________________________
______________________________________________________________
I am enrolled in a public school special education program for the blind or state residential school for the blind.
[
] Yes [ ] No If yes, please specify: _______________________________
______________________________________________________________
I am registered with a cooperating regional library under the program of The National Library Service for the Blind and Physically Handicapped, Library of Congress.
[
] Yes [ ] No If yes, please specify: _______________________________
______________________________________________________________
If you answered no to all the above questions, you must include with this application a letter from one of the following certifying that you are blind.
[ ] Your doctor
[ ] Social Security Award letter
[ ] President of a local chapter or state affiliate of the National Federation of the Blind
[� ] Teacher of the visually impaired/ O&M Instructor
I certify that I am blind or visually impaired and unable to read a printed newspaper.
SIGNATURE: ________________________________ DATE: ___________
PLEASE RETURN THE COMPLETED FORM TO THE ADDRESS ABOVE