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Application for Spring '07 Vocational Classes

Name: _____________________________________________________
Street/City: __________________________________________________
Zip: _______________________ Phone: __________________________
Email: ______________________________________________________

Do you have a disability of any sort?         Yes ___ No ___
Are you receiving Medicaid?                      Yes ___ No ___
Do you have a Ticket to Work?                  Yes ___ No ___
Are you on SSI? SSDI?                              Yes ___ No ___
Are you on VR (Voc Rehab)?                     Yes ___ No ___  Pending ___
        if yes, is VR paying for this?               Yes ___ No ___  Maybe ___

Have you used our services before?          Yes ___ No ___

Would you like to sign up for the Independence, Inc. newsletter?
        Yes ___ No ___ Already Receive ___

If yes, which version would you prefer?

Print ___ Email ___ Braille ___ Audio _____

*************************************************************

Program Applied For (please choose only 1):

• Information Technology Careers I ___  
  (Meets Saturdays, 12 - 4 PM, Jan 20 - May 12, 2007)  

• Office Assistant ___  
  (Meets Tue through Fri, 8:30 - 10:20 AM, Jan 16 – May 18, 2007)  

*************************************************************  

Print out, mail or return this completed form to:

Independence, Inc.
attn: Mark Creamer
2001 Haskell Avenue
Lawrence , KS 66046

Phone: 785-841-0333
Toll Free: 1-888-824-7277
TDD (785) 841-1046

Fax: (785) 841-1094

 Email:  markc@independenceinc.org

Online Application: http://independenceinc.org/forms.html