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.

* All fields marked with an asterisk are required fields

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I am interested in the following service(s):

Special Services (Optional):

Basic Information

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Personal Information



Medical Information


Service Information

Consent for Release of Information

Note: Only the applicant or the applicant's parent/guardian can authorize the Consent for release of information.

I authorize the Division of Blind Services to release and/or obtain information from:

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