DIVISION OF VOCATIONAL REHABILITATION
REFERRAL FOR VOCATIONAL REHABILITATION SERVICES

I am a person with a mental or physical impairment that interferes with my ability to work. I want to learn more about the rehabilitation services available through the Division and how they can assist in securing or retaining employment.

Name:_________________________________________________________________
Social Security Number:_____________ Date of Request:_________________
Address:______________________________________________________________
City:________________________________ State:________ Zip:_____________
Date of Birth:___________________ Sex: _______________________________
Telephone number where you can be reached:____________________________
Name of a contact person:_____________________________________________
Telephone number of the contact person:_______________________________
What prevents you from working?_______________________________________
______________________________________________________________________
______________________________________________________________________
Do you require any accommodation for your impairment? If yes, please explain: ______________________________________________________________________
______________________________________________________________________
If referral is by an agency or other person,

                       Name: Robert "Soaring Eagle" DeLong
Address of Agency or Person:Native American Outreach Program
                            322 Orchis Road
                            St. Augustine, FL.  32086
Telephone Number: Home Office - 904-797-4540
                  Cell Phone -  904-874-0988
                  Cell Phone -  904-347-4504
                  Cell Phone -  904-501-1938

(Print and complete the above information and send the entire form to the nearest Vocational Rehabilitation office or address above)
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(Please do not complete the information below until you speak with a counselor)

I understand that the purpose of receiving vocational rehabilitation services is to enable me to retain or secure employment. I understand that I must be found eligible for the services that I require.

____________________________
Signature of Parent or Guardian

Referral for vocational rehabilitation have the right to be interviewed and provided an explanation in the event the application is denied or is not acted upon with reasonable promptness. Services, financial aid and other benefits under the Vocational Rehabilitation program are provided on a non-discriminatory basis as required by Title VI of the Civil Rights Act of 1964. Individuals have the right to file a complaint with the Florida Division of Vocational Rehabilitation or the Rehabilitation Service Administration of the United States Department of Education if they believe that the discrimination is being practiced in the program on the basis of sex, race, color, religion, national origin, age, marital status, political affiliation, disability, or veteran status.