Vocational Rehabilitation Program Application Vocational Rehabilitation Program Application Name:(Required) First Middle Last Preferred Name: Previous Name or Names: Birthdate:(Required) Tribal Affiliation:(Required) Roll Number:(Required) Gender:(Required) Pronouns:(Required) Email:(Required) Cell Phone:(Required)Secondary Phone:Home Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mailing Address (if different that above): Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Have you been a VR client before?(Required) Yes No Preferred LanguageWhat language do you want us to use with you?(Required) English Spanish ASL Other Do you need an interpreter for us to communicate with you?(Required) No Yes, sign language Yes, spoken language What kind: ASL, PSE, ProTactile, etc.? Which language? CitizenshipAre you a U.S. citizen?(Required) Yes No Do you have documents that show you can legally work in the United States?(Required) Yes No Emergency contact or contacts (optional)Provide information for people who will be able to help us contact you.Name(Required) Relationship(Required) Phone(Required)Name(Required) Relationship(Required) Phone(Required)Where do you live?(Required) Private home or apartment Houseless Other Your relationship status(Required) None Divorced Domestic partnership Married Separated Widowed How did you learn about VR?Name of person or organization that referred you to VR: Phone or email if available: Support you receiveCurrently receiving:(Required) SSI SSDI Neither Do you have a court appointed legal guardian?(Required) Yes No What is their name, phone number, and email? (Please bring court papers to your first meeting with VR)(Required) Do you have a representative payee?(Required) Yes No What is their name, phone number, and email?(Required) Medical Insurance(Required)Check all that apply: None ACA Exchange Medicaid Medicare Not yet eligible for insurance from my job OHP (Oregon Health Plan) OHP Plus Private insurance through my job Private insurance (other sources) Public insurance (other sources) Workers’ Compensation Education InformationHigh SchoolLatest high school attended:(Required) City and state:(Required) Graduation year:(Required) Graduation Status(Required) Certificate of completion/attendance Did not complete GED Modified diploma Standard diploma CollegeName of school: Credential: Year obtained: Other InformationDo you need VR to help keep your job?(Required) Yes No Are you a migrant or seasonal farmworker?(Required) Yes No Are you a veteran?(Required) Yes No Were you injured during your military service?(Required) Yes No Are you working with a mental health program?(Required) Yes No CommentsThis field is for validation purposes and should be left unchanged.
