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* 1. This form filled out by:  (staff initials) 

CLIENT CONTACT INFORMATION

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* 2. Full name:

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* 3. Residential address:

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* 4. Mailing address:

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* 5. Best phone number we can reach you at:

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* 6. Email address:

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* 7. Date of Birth:

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* 8. Gender (For statistical purposes only):

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* 9. Ethnicity (For statistical purposes only):

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* 10. Annual Income (For statistical purposes only):

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* 11. Language Spoken:

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* 12. Do you need a language interpreter:

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* 13. Are you a Veteran:

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* 14. Are you currently receiving Services from any agency such as Ho’opono DVR, ATRC, Abilities Unlimited, Helen Keller Foundation, etc.? If Yes, please specify:

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* 15. What service animal or guide dog, if any, do you use?

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* 16. How did you hear about GDH?

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* 17. Please specify your preferred method of communication:

SECTION 2: ELIGIBILITY 

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* 18. Cause of legal blindness:

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* 19. When were you determined legally blind?

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* 20. Proof of Legal Blindness (form N-172, certification from MD, DVR, VA, COMI):

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* 21. Proof of Residency (utility bill, State ID, Handi-Van Pass, etc.)

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* 22. Emergency Contact (must be 18 or older)

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* 23. Full Name

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* 24. Phone

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* 25. Relationship

CONSENT STATEMENTS

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* 26. I understand that by registering I am a client entitled to request for available services and enroll in periodic projects that I may be eligible for and that I may be required to provide additional information that will help to determine my eligibility for requested services or periodic project enrollment.

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* 27. Signature

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