As part of your application, we need to have you print out the following Authorizations 
For Release of Information forms, fill them out completely, sign them, and mail them to:  
Living Skills Center for the Visually Impaired, 2430 Road 20, Apt. B112, San Pablo, CA 
94806.



AUTHORIZATION FOR RELEASE OF INFORMATION

I, ______________________________________________, hereby authorize
        (Print Your Name)

__________________________________       _________________________
        (High School)			                         (Street Address)

__________________________________
	(Itinerant Teacher)

__________________________________      __________________________
        (City/State/Zip)		                                         (Phone)

To Release Information To:
Living Skills Center for the Visually Impaired
2430 Road 20, #B112
San Pablo, CA 94806

__________________________________     ___________________________
        (Signature of Applicant	                           (Date) (Release for Six Months)

This information will be used to assist in determining eligibility for the Living Skills 
Center clients.

































AUTHORIZATION FOR RELEASE OF INFORMATION

I, _______________________________________________, hereby authorize
           (Print Your Name)

__________________________________    ____________________________
           (Mobility Instructor)                                    (Street Address)

__________________________________    ____________________________
           (City/State/Zip)                                             (Phone)

To Release Information To:
Living Skills Center for the Visually Impaired
2430 Road 20, #B112
San Pablo, CA 94806

__________________________________     ____________________________
           (Signature of Applicant)                        (Date) (Release for Six Months)

This information will be used to assist in determining eligibility for the Living Skills 
Center clients.






































AUTHORIZATION FOR RELEASE OF INFORMATION

I, _______________________________________________, hereby authorize

__________________________________    ___________________________
     (Personal Physician)                                        (Street Address)

__________________________________    ___________________________
     (City/State/Zip)                                                 (Phone)

To Release Medical Information To:
Living Skills Center for the Visually Impaired
2430 Road 20, #B112
San Pablo, CA 94806

__________________________________     ___________________________
     (Signature of Applicant)                                (Date) (Release for Six Months)

__________________________________
 	(Medical Record Number)

This information will be used to assist in determining eligibility for the Living Skills
Center clients.









































AUTHORIZATION FOR RELEASE OF INFORMATION

I, ________________________________________________, hereby authorize

___________________________________    ___________________________
     (Eye Doctor)                                                    (Street Address)

___________________________________    ___________________________
     (City/State/Zip)                                                (Phone)

To Release Medical Information To:
Living Skills Center for the Visually Impaired
2430 Road 20, #B112
San Pablo, CA 94806

____________________________________    __________________________
    (Signature of Applicant)                                 (Date) (Release for Six Months)

_____________________________________
	(Medical Record Number)

This information will be used to assist in determining eligibility for the Living Skills 
Center clients.








































AUTHORIZATION FOR RELEASE OF INFORMATION

I, ________________________________________________, hereby authorize

___________________________________    ___________________________
     (Rehabilitation Counselor)                               (Street Address)

___________________________________    ___________________________
    (City/State/Zip)		                               (Phone)

To Release Information To:
Living Skills Center for the Visually Impaired
2430 Road 20, #B112
San Pablo, CA 94806

Information requested:  eye reports, medical reports, audiological, psychological,
And training program reports (i.e. vocational, living skills, mobility, technology).

___________________________________    _____________________________
    (Signature of Applicant)                                (Date) (Release for Six Months)