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Student Transition & Enrichment Program

Adult Programs Inquiry Form

Thank you for your interest in Junior Blind's teen and adult services! Please complete the form below and our program directors will be in touch.

Please note: This form asks for Protected Health Information (PHI) and is stored on a secure server. Access to this information is granted only to Junior Blind staff who have a need to access the information to complete the request that has been made. For more information on Junior Blind’s privacy practices, please view our Notice of Privacy Practices.

Contact Information

First name:
Last name:
Parent first and last Name:
Required for inquiring students younger than 18 years of age
Email address:
Phone:
Address:
City:
State:
Zip code:
County:
Date of birth:
Gender:

Program Information

Program desired:
Desired start date:
Program goals:

Visual Imapirment and Other Disabilities

Degree of vision:
Onset of visual impairment:
Additional disabilities:
Accommodations:

Referral

Referred by:
Referrer's first and last name:
Referrer's email address:
Program funding source:

Eduation

Are you currently enrolled in school?
School:
School city and state:

Demographics (Optional)

Please note that the following questions are optional and are used for reporting purposes only.

Ethnicity:
Personal annual income:
Household annual income:
If the below fields are visible, ignore them.


Accept Terms?