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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.

* All fields marked with an asterisk are required fields

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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

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:
I am the parent or guardian of the applicant, and I authorize the Division of Blind Services to release and/or obtain information from:
I am not requesting consent to release 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

*This application is being submitted to apply for services from the Division of Blind Services and all eligibility is determined without regard to race, color, religion, sex, national origin, age, marital status, or disability.
Applicant Signature
Applicant Signature	Date	11/21/2024
Parent or Guardian Information (If Applicable)
Parent or Guardian Signature		Relationship		Date 11/21/2024
Parent/Guardian Last Name	Parent/Guardian First Name		Parent/Guardian Phone
Provider Information (If Applicable)
Provider Name	Provider Signature		Date	11/21/2024
DBS Staff (If Applicable)
DBS Staff Signature	Date	11/21/2024
Other (If Applicable)
Affiliation/Company	Submitter Signature		Date	11/21/2024