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Knud Hansen Complex Suite 1 • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802-6722 • (340) 774-0930 #2 Estate Carlton • Frederiksted, St. Croix, Virgin Islands 00840 • (340) 643-8145 INDEPENDENT LIVING SERVICES FOR OLDER INDIVIDUALS WHO ARE BLIND Application for Services CLIENT INFORMATION: NAME_______________________________________ DATE OF APPLICATION__________ SOCIAL SECURITY________________________ GENDER (M) (F) ETHNICITY (Black/African) (Hispanic/Latino) (Caucasian) (Other) DATE OF BIRTH___________________ PLACE OF BIRTH___________________ CITIZENSHIP STATUS______________________ IF NOT A U.S. CITIZEN, ALIEN REGISTRATION #___________________ PHYSICAL ADDRESS MAILING ADDRESS _________________________________________ _______________________________________________ __________________________________________ ________________________________________________ TELEPHONE NUMBER HOME___________________________ WORK_________________________ CELL________________________ ARE YOU EMPLOYED: [ ] YES [ ] NO TYPE OF EMPLOYMENT_________________________________________________________________________ • Do you need visual aides to complete your job duties? [ ] YES [ ] NO • Do you need reader services to complete your job duties? [ ] YES [ ] NO PERSON TO CONTACT IN AN EMERGENCY _____________________________________________________________________________________ NAME TELEPHONE NUMBER REFERRAL SOURCE _____________________________________________________________________________________ NAME AGENCY OR RELATIONSHIP ILS For Older Blind Application for Services I. DO YOU ATTEND A SENIOR CITIZEN CENTER? YES [ ] NO [ ] IF YES, CENTER’S NAME AND ADDRESS __________________________________________________________________________ __________________________________________________________________________ II. DO YOU LIVE INDEPENDENTLY? YES [ ] NO [ ] [ ] OWN HOME [ ] WITH RELATIVES [ ] IN A SENIOR CITIZEN HOME/HOUSING COMMUNITY – GIVE NAME AND ADDRESS __________________________________________________________________________ __________________________________________________________________________ III. HIGHEST LEVEL OF EDUCATION COMPLETED [ ] NO FORMAL SCHOOLING [ ] ELEMENTARY EDUCATION (GRADES 1-8) [ ] SECONDARY ED., NO HIGH SCHOOL DIPLOMA (GRADES 9-12) [ ] POST SECONDARY ED (LESS THAN BACHELOR’S DEGREE) [ ] MASTER’S DEGREE OR HIGHER IV. VISUAL IMPAIRMENT/DISABILITY [ ] TOTALLY BLIND [ ] LEGALLY BLIND [ ] SEVERE VISUAL IMPAIRMENT V. MAJOR CAUSE OF VISUAL IMPAIRMENT [ ] MACULAR DENGENERATION [ ] GLAUCOMA [ ] DIABETIC RETINOPATHY [ ] CATARACT [ ] OTHER [ ] RESPIRATORY OR LUNG CONDITIONS [ ] OTHER ILS For Older Blind Application for Services Knud Hansen Complex Suite 1 • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802-6722 • (340) 774-0930 #2 Estate Carlton • Frederiksted, St. Croix, Virgin Islands 00840 • (340) 643-8145 VI. DO YOU USE VISUAL AIDS? YES [ ] NO [ ] IF YES, PLEASE LIST THE VISUAL AID USED _____________________________________________________ CAN YOU BENEFIT FROM ANY OF THISE LISTED BELOW? [ ] EYE GLASSESS [ ] TALKING CALCULATOR [ ] TALKING WATCH [ ] LARGE NUMBER WATCH [ ] JUMBO BUTTON PHONE [ ] CCTV [ ] VOICE ACTIVATED RECORDER [ ] HAND HELD MAGNIFIER [ ] LARGE SCREEN CALCULATOR [ ] LCD DIGITAL CLOCK [ ] CANE/WALKING STICK [ ] LARGE PRINT DICTIONARY [ ] OTHER SPECIAL NEEDS THAT YOU MAY HAVE VII. NON-VISUAL IMPAIRMENTS/CONDITIONS [ ] HEARING IMPAIRMENT [ ] MENTAL IMPAIRMENT [ ] CANCER [ ] DIABETES MELLITUS [ ] CARDIAC AND OTHER CONDITIONS OF THE CIRCULATORY SYSTEM [ ] END STAGE RENAL DISEASE AND GENITOURINARY SYSTEM DISORDER [ ] MUSCULOSKELETAL (ARTHRITIS, RHEUMATISM, AMPUTATIONS, FRACTURES/INJURIES WHICH RESULTED IN PERMANENT LOSS/IMPAIRMENT OF LIMB FUNCTION) [ ] RESPIRATORY OR LUNG CONDITIONS [ ] OTHER Applicant Signature Date