Sign Up for LightHouse Programs * These fields are required.From expert skills training to fun one-off events, LightHouse offers a range of workshops, activities and services for individuals with eyesight of all levels. We collect information about all of our students in order to determine general eligibility for services and ensure we tailor our programming to specific needs. If you need a trained LightHouse staff member to help with the sign-up process, give us a call at (415) 694-7323. Note: Your responses are confidential and will only be seen by qualified LightHouse staff. If you are referring someone else, please answer the questions as best you can on behalf of the person you are referring. We will need to talk to them directly so that we can assess if they are ready to move forward with our programs. Contact Information First Name * Nickname Last Name * Personal Pronoun Email Primary Phone * Phone Type * --None--HomeMobileFaxWorkTTY/VP How did you hear about LightHouse? * --None--Assisted Living FacilityCollege/University/SchoolCommunity Rehabilitation ProgramCommunity Senior ProgramConference/Meeting/EventD O REmail newsletterEmployer/Co-workerEye Care ProviderOther Medical ProviderFaith-Based OrganizationFamily Member/FriendIndependent Living CenterInternet SearchLightHouse EventLightHouse StaffLightHouse StudentLightHouse VolunteerLightHouse WebsiteOther Blindness OrganizationRegional CenterSelf-initiatedSocial MediaSocial Services AgencyTV/Radio/NewspaperTVI/O&M Specialist (K-12)VAOther Sources If you can recall more specifically, please elaborate. Mailing Address Street Address * City * State --None--AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Zip * Country * United StatesAfghanistanAland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia, Plurinational State ofBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, the Democratic Republic of theCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, the former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMartiniqueMauritaniaMauritiusMayotteMexicoMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorwayOmanPakistanPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuela, Bolivarian Republic ofViet NamVirgin Islands, BritishWallis and FutunaWestern SaharaYemenZambiaZimbabweEmergency Contact Info If you are under 18, your emergency contact MUST be a parent or guardian. Emergency Contact Name * Emergency Contact Relationship * Emergency Contact Phone * Vision, Hearing and Health Info What is your level of vision?* * --None--Low Vision (not legally blind)Legally BlindTotally BlindNot Blind/Low Vision Primary Cause of Vision Loss * -None--AlbanismCataractsCMVCVIDetached RetinaDiabetic RetinopathyGlaucomaLeber's Congenital AmaurosisMacular DegenerationOptic Nerve AtrophyOptic Nerve HypoplasiaRetinitis PigmentosaROP/RLFStargardtsStrokeTraumaUshers SyndromeUnknown CauseOtherN/A Level of hearing * --None--Hard of hearing - understands speechHard of hearing - cannot understand speechTotally DeafNot deaf or hard of hearing Additional Notes about Vision/Hearing Do you have any medical conditions or disabilities other than blindness? Please include information about medications or treatment that we should be aware of. * Do any conditions affect the following: Communication? * --Select One--YesNo Mobility? * --Select One--YesNo Cognition? * --Select One--YesNo Mental Health? * --Select One--YesNo Other? * --Select One--YesNo If other, please specify. Do you have any other special considerations (medical or otherwise) or accommodation needs that we may need to be aware of? If so, please describe them. * Do you have any dietary restrictions or allergies that we should be aware of? If so, please describe them. * Program Interest What is the *primary* service or activity you are interested in participating in at the LightHouse? * --None--30% & Growing eventsAssistive technology trainingBlind and Low Vision Skills Training: Support services, orientation and mobility, daily living skills, braille, cooking skills, etc.Counseling and mental health resourcesDeaf blind programmingEmployment servicesEmployment workshopGuide Dog WorkshopMilestones MeetupsSocial/recreational activities to meet others who are blind or experiencing a change in visionSummer campVolunteer Services: Personal Service Volunteer or Fitness PartnerWoodworking Workshop at Enchanted Hills CampYouth ProgramsYouth Transition Activities and ServicesYES Summer Academy Who, if anyone, is your LightHouse point of contact? Please provide any additional information about your needs and interests that may help us better follow up with you. Demographic Information Please complete all questions below. If you choose not to disclose some of this information, simply select 'Declined' from among the drop-down options. This information will NOT affect eligibility in any LightHouse programming. Demographic information is collected to help in funding our programs and making our services as inclusive as possible. All responses will be kept confidential and only reported in the aggregate. Thank you! Birthdate (mm/dd/yyyy) * Sexual orientation/Sexual identity * --None--Straight / HeterosexualBisexualGay / Lesbian / Same-Gender LovingQuestioning / UnsureOtherDeclined If other, please specify. Gender * --None--MaleFemaleTrans MaleTrans FemaleGenderqueer / Gender Non-binaryOtherDeclined Sex at birth * --None--MaleFemaleDeclined Ethnicity * --None--AfricanAfrican AmericanAlaska NativeAsian OtherCambodianCaucasianChineseEastern European/RussianFilipinoJapaneseKoreanLaotianLatino/HispanicMiddle EasternNative AmericanPacific Islander/Native HawaiianVietnameseMulti-EthnicOtherDeclined Primary language * EnglishArabicASLCantoneseCzechDanishDutchEnglishFrenchGermanGreekHaitian CreoleHindiHmongHungarianItalianJapaneseKoreanMalay/IndonesianMandarinNorwegianNepaliPersianPolishPortuguesePunjabiRomanianRussianSomaliSpanishSudaneseSwedishTagalogThaiTurkishUkrainianUrduVietnameseOtherDeclined Type of residence * --None--Assisted Living CenterHomelessLong Term Care FacilityPrivate ResidenceSenior Living/Retirement CommunityShelterSROOtherDeclined Number of people in household * --None--12345678910 Monthly household income * --None--0 - 1,0001,001 - 2,0002,001 - 3,0003,001 - 4,0004,001 - 5,0005,001 - 6,0006,001 - 7,0007,001 - 8,0008,001 - 9,0009,001 - 10,00010,001 - 11,00011,001 - 12,00012,001 - 13,00013,001 - 14,00014,001+Declined Highest level of education completed * --None--No Formal SchoolingElementary (grades 1 - 8)Secondary, no high school diploma (grades 9 - 12)High School or Equivalency CertificatePost Secondary Education/Some CollegeBachelors DegreeMasters Degree or HigherDeclined Are you a veteran?** * --None--YesNoDeclinedStay Informed Want to stay in the loop about news, opportunities and exciting developments at the LightHouse? Please review the options below and choose (ctr/cmd+click) as many as you wish. Weekly E-mail NewsletterMonthly Youth eNewsletterQuarterly BrailleQuarterly Large PrintQuarterly CassetteReferring someone else? If you are referring someone other than yourself, please enter YOUR name, phone number/email and relationship to the person you are referring. * Legal blindness is a level of vision loss that has been legally defined to determine eligibility for benefits. The clinical diagnosis refers to a central visual acuity of 20/200 or less in the better eye with the best possible correction, and/or a visual field of 20 degrees or less.** A veteran is a person who served in the active military, naval, or air service, and who was discharged or released there from conditions other than dishonorable.