Application Services

Help

Help

Help
Provides description of the input fields on the Online Application Page

Programs (Required)
Select the program that you would like to request the services under

Blind Babies Program (Birth - Age 5)
Provides community-based early intervention education for children from birth through five years of age who are blind or visually impaired, and for their parents, families, and caregivers

Children’s Program (Age 6 - Age 13)
Provides family involvement, communication, social skills, mobility, sensory development, literacy experiences, self-care and independence, and assists school-age children who have visual impairments to meet current and future challenges

Independent Living (Age 18 over)
Training for daily living activities necessary for independence. Community rehabilitation contractors provide training on techniques and devices that regain and enhance independence. Senior citizens are the largest age group of people with diminished vision

Transition Services (Pre-employment Age 14 - Age 21)
Provides education, training, equipment and skills needed for success when a visual impairment is a barrier to employment. Services begin at age 14 and continue through to successful employment

Vocational Rehabilitation (Employment Related Services)
Provides assistance in employment related services that include Post-Employment Services, Supported Employment Services, Self-Employment Services and Business Enterprise Services when a visual impairment is a barrier to employment

Other
Other Programs that are not specified in the list

Specific Services (Optional):
Select the specific services that you would like to receive that includes:

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 (Required)
Last Name of the person requesting services

First Name (Required)
First Name of the person requesting services

MI
Middle Initial of the person requesting services

SSN
Social Security Number of the person requesting services

Date of Birth (Required)
Date of Birth of the person requesting services

Street Address or PO Box (Required)
Street Address or P O Box of the person requesting services

Apt Number
Apartment Number if applicable of the person requesting services

City (Required)
City name where the person requesting services resides

State (Required)
State where the person requesting services resides

County (Required)
County where the person requesting services resides

Zip Code (Required)
Zip Code where the person requesting services resides

Directions to home
Provide direction information to the home of the person requesting services

Email
Email address information of the person requesting services

Home Phone (Only one phone number is required)
Home phone information of the person requesting services

Cell Phone
Cell phone information of the person requesting services

Work Phone
Work phone information of the person requesting services

Personal Information:

Race
Ethnicity/Race information of the person requesting services. A person can choose from one or more choices shown below:

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 (Required)
Gender information of the person requesting services

Marital Status
Marital status information of the person requesting services

Language
Language medium of the person requesting services

Registered Voter
Is the person requesting services is a registered voter

Veteran
Is the person requesting services is a veteran

Highest Level of Education
Highest level of education of the person requesting services

School last attended and Date
If applicable the last school attended and the date attended of the person requesting services

Employed
Is the person requesting services is currently employed

Full time/Part time
If applicable the person requesting services is employed fulltime or part-time

Title
Job title if applicable person requesting services is a veteran

US Citizen
Is the person requesting services is a US Citizen

If no, list status
The status of the person requesting services if not a US Citizen

Medical Information:

Eye Condition
Eye condition of the person requesting services

Eye Physician
The name of the physician of the person requesting services

Visual Impairment in Both Eyes?
Is the person requesting service has visual impairment in both eyes?

Date last seen
The date information when the person requesting services was last seen by the physician

Secondary Disabilities
If applicable any secondary disability information for the person requesting services

Services Information:

Have you received services from this agency?
If the person requesting services has received services from Florida Division of Blind Services

If yes, when
The date when the person received services from Florida Division of Blind Services

I would like information in:
Medium in which the person requesting services would like the information (regular print, large print, email/CD or braille)

Additional Comments
Provide any additional comments

Consent for release of information:

I authorize the Division of Blind Services to release and/or obtain information from:
By selecting the checkbox, the user authorizes Division of Blind Services to release information to the mentioned eye medical provider or facility.

Eye Medical Provider or Facility (Required if Consent Checkbox is checked)
Name of the Eye medical provider or the facility

Address (Required if Consent Checkbox is checked)
Complete street address of the provider or facility

City (Required if Consent Checkbox is checked)
City of the provider or facility

State (Required if Consent Checkbox is checked)
State abbreviation of the provider or facility

Zip (Required if Consent Checkbox is checked)
Zip code of the provider or facility

Phone (Required if Consent Checkbox is checked)
Primary contact phone of the provider or facility

Fax
Fax number of the provider or facility

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. (Required)
Acknowledgement for applying for services with Florida Division of Blind Services

Signature
Signature of the person requesting services.

Date
Date the service was requested

Parent or Guardian Information (if applicable):

Parent/Guardian Signature
Signature of the Parent or Guardian representing the person requesting services

Date
Date the service was requested

Last Name (Required if parent or guardian represents)
Last Name of the Parent or Guardian representing the person requesting services

First Name (Required if parent or guardian represents)
First Name of the Parent or Guardian representing the person requesting services

Phone (Required if parent or guardian represents)
Phone Number of the Parent or Guardian representing the person requesting services

Relationship
Relationship information of the parent or guardian representing the person requesting services

Provider Information (if applicable):

Provider Name (Required if provider represents)
Name of the Provider representing the person requesting services

Provider Initials (Required if provider represents - 3 digits)
Initials of the Provider representing the person requesting services. Provider can enter the initials or abbreviation of the firm

Date
Date the service was requested

Print
Click on the Print button opens a PDF version of the application submitted online

Email
This button is displayed if email address is provided by the application. Click on the Email button send a confirmation email to the applicant for the submitted application

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.

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

* 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
Applicant Signature	Date	4/1/2023
Parent or Guardian Information (If Applicable)
Parent or Guardian Signature	Relationship		Date	4/1/2023
Parent/Guardian Last Name	Parent/Guardian First Name		Parent/Guardian Phone
Provider Information (If Applicable)
Provider Name	Provider Initials		Date	4/1/2023

I am interested in the following service(s):

Basic Information

Personal Information

Medical Information

Service Information

Consent for release of Information

Disclosure and Signature

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

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

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

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.