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Department of Education Division of Blind Services

Social Security Number Collection Policy

In compliance with Section 119.071(5), Florida Statutes, this statement serves to notify you of the purpose for the collection and usage of your social security number by the Florida Department of Education, Division of Blind Services (“Division”).

You will be asked to provide your Social Security Number (SSN) on this application. Social Security Numbers are collected as part of the process of helping blind or visually impaired individuals gain meaningful employment and thereby increase their independence and self-sufficiency. If you choose not to provide your SSN on this form, the Division will contact you for your SSN and any additional information that may be needed to complete the application process.

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I am interested in the following service(s):

Programs:
Blind Babies Program (Birth - Age 5) Children's Program (Age 6 - Age 14) Independent Living (Age 18 Over)
Transition Services (Age 14 - Age 21) Vocational Rehabilitation (Employment Related Services)
Other
Special Services (Optional):
Orientation and Mobility Braille Instruction & Communication Services Assistive Technology Services
Home & Personal Management Services Student Readiness Services Employment Services
Supported Employment Services Self-Employment Services Business Enterprise Services
I am not sure

Basic Information

Last Name * First Name * MI
SSN DOB *
Street Address or PO Box * Apt Number City *
State * County * Zip *
Directions to your home Email
Home Phone Cell Phone Work Phone

Personal Information

Race American Indian or Alaskan Native
Asian
Black or African American
Caucasian or White
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Not Available
Sex * Marital Status Language
Registered Voter Are you a Veteran
Highest Level of Education Last School Attended/Date
Are you employed If yes, full time/part time Title
US Citizen If no, list status

Medical Information

Eye Condition Eye Physician Visual Impairment in Both Eyes?
Date Last Seen Secondary Disabilities

Service Information

Have you ever received services from this Agency? If yes, when?
I would like information in
Additional Comments

Consent for release of Information

I authorize the Division of Blind Services to release and/or obtain information from:
Eye Medical Provider or Facility
Address
City State Zip
Phone Fax

Purpose: This information will only be used for my plan of services and will not be released to anyone else without my written request. I authorize the one-time use or disclosure of the information described above to the person/provider/organization/facility/program(s) identified. My authorization will expire when the requested information has been sent/received.

I understand that I may cancel this authorization at any time by submitting a written request to the Division, except where a disclosure has already been made in reliance on my prior authorization.

Disclosure and Signature

* I understand that I am applying for services from the Division of Blind Services and that all eligibility is determined without regard to race, color, religion, sex, national origin, age, marital status, or handicap.
Applicant Signature
Parent or Guardian Information (If Applicable)
Provider Information (If Applicable)