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Family Member and Acquaintance Referral Form

Family Member and Acquaintance Referral Form

CONFIDENTIALITY STATEMENT This referral form uses security protocols and the information provided is confidential pursuant to 34 CFR 361.38. The Commission for the Blind will use the information only for the purpose of providing Vocational Rehabilitation or Independent Living services.

Name of Person Making Referral:(Required)

Referring Person Contact Information

Address:(Required)
Name of Person Being Referred:(Required)
Address:(Required)
Relationship to Person Being Referred:(Required)

Visual Condition of Person Being Referred:(Required)
Age of Person Being Referred:(Required)
Person Being Referred Needs Help with (check all that apply)(Required)
Person being referred is aware of and consents to this referral to the Commission for the Blind:(Required)