Transition: Employment, Advocacy, Mentoring and Skills (TEAMS) Program Application

For blind high school students Age 14 to 21

DATE OF APPLICATION:______

NAME OF APPLICANT:______

STREET ADDRESS:______

CITY: STATE: ZIP CODE:

HOME PHONE:( ) E-MAIL:

PARENT/S NAME/S: ______

STREET ADDRESS (if different from above): ______

CITY: STATE: ZIP CODE: ______

HOME PHONE (Mom): ( )______

WORK PHONE (Mom): ( )______

HOME PHONE (Dad): ( )______

WORK PHONE (Dad): ( )______

EMERGENCY CONTACT (other than parents) NAME: ______

EMERGENCY PHONE: ( )______

GENERAL INFORMATION

MALE OR FEMALE: AGE: DATE OF BIRTH: ______

NAME OF HIGH SCHOOL:______GRADE IN SCHOOL:______

VOCATIONAL GOAL(S):______

CAUSE OF BLINDNESS: ______

NAME, Email and PHONE NUMBER OF APPLICANT'S Vision teacher:

______

NAME, Email and PHONE NUMBER OF APPLICANT'S STATE VOCATIONAL REHABILITATION COUNSELOR: (REQUIRED):

______

BLINDNESS SKILLS TRAINING

Do you know Braille? _____ YES _____ NO

If yes, Grade 1 or Grade 2?______Words per minute (reading):______

What do you use to write Braille (Mark all that apply)?

Slate and Stylus _____ Brailler _____ Notetaker (i.e., Braille Lite, Braille Note)______

Do you use a cane? _____ YES _____ NO

Have you had any computer training? _____YES _____NO

If yes, using which program for accessibility (i.e., JAWS, Window-Eyes, ZoomText, iDevice/apple computer with Voiceover, refreshable Braille display, etc.)?

______

HOBBIES/INTERESTS:

______

MEDICAL INFORMATION

Do you take any medication on a regular basis? ____YES ____NO (please detail below)

Name of Medication

/ Dosage & Time Taken / Reason for Medication / Do You Administer Medication Independently? / Additional Comments

Do you have any allergies? ____YES ____NO (explain) ______

______

Do you have any dietary restrictions? ____YES ____NO (explain) ______

______

Name of Insurance Provider: ______

Policy Number: ______

Please list any other questions or concerns that you may have,

or information that you would like us to be aware of.

______

______

______

______

______

Signature of Applicant Date

______

Signature of Parent or Legal Guardian Date

(if applicant under 18 years of age)

Please return this application to: BLIND, Inc., 100 East 22nd Street, Minneapolis, MN, 55404, Attn: Transition Programs. You can also fax it to us at 612-872-9358 or scan and email it to

.

We invite you to take a tour of our facilities and learn more about our program. Please call (612) 872-0100, or our toll-free number 1-800-597-9558, to arrange a visit.

The National Federation of the Blind (NFB) training center in Minnesota