Home Stay Program Application Name (required) Address (required) Phone (required) Email (required) Date of Birth (required) How much remaining vision, if any, do you have? (required) When did you start experiencing significant vision loss? (required) Describe your current skill level in the following areas. (required) Braille ExcellentGoodSatisfactoryPoorNone Mobility with the White Cane ExcellentGoodSatisfactoryPoorNone Cooking ExcellentGoodSatisfactoryPoorNone Technology using speech output ExcellentGoodSatisfactoryPoorNone Life skills such as budgeting and time management ExcellentGoodSatisfactoryPoorNone How would you describe your general health? (required) Please describe any other disabilities or health conditions you experience, besides vision loss. (required) Are you prepared to commit to a 8-16 week program? (required) YesNo Are you prepared to wear learning shades during your training sessions? (required) YesNo Your training is free of charge, but accommodations will cost $125 per week. Would you require subsidy? YesNo If you answered 'Yes' to the previous question, please answer the next three. If you answered 'No', you may now hit "Send" What is your current gross monthly income? Will you continue paying for your current accomodation during your participation in the program? If so, how much? Describe any other financial obligations you will have during the program. Please leave this field empty.