Intake Application for SSP Services
Please complete this form to determine if you meet the criteria to receive SSP services. Questions? Email us at deafblindservices@vancro.com or 802.468.7780
Which state SSP program are you applying to? *
- New Mexico
- Nebraska
- Vermont
*Alert* Missouri SSP Grant participants
Vancro is no longer accepting SSP requests for general requests under the SSP grant. Only SSP requests for SASI and Missouri Society for the Blind and Visually Impaired.
State *
- MO
- VT
- NM
- NE
Please note if it is voice, text, or VP.
Preferred Method of Communication *
Select all that apply
- Text
- Email
- VP
- Voice Call
- Text and email
Which best describes your level of hearing? *
- Deaf
- Hard of Hearing
- Late-Deafened
- Other
Which best describes your vision? *
- Sighted
- Blind
- Tunnel Vision
- Close Vision
- Other
- Low Vision
Please describe your preferred communication method *
Select all that apply
- American Sign Language (ASL)
- Signed Exact English (SEE)
- Pidgin Signed English (PSE)
- High Visual Communication Skills (HVCS/MLS)
- Tactile ASL (TASL)
- Spoken English
- Other Spoken Language
- Other Signed Language
What is your preferred method to read written English? *
- Regular Print
- Large Print
- Braille grade 1 (uncontracted)
- Braille grade 2 (contracted)
- Computer Braille
- Electronic/Screen Reader
Do you agree to pay for any incidental or activity expenses? *
Ex. parking meters, bus fare, entrance fee, event tickets, etc.
- Yes
- No
Do you grant permission for the SSP to assist with emergency situations? *
Please note that Vancro, any state agencies, and the SSP are NOT responsible for any medical costs incurred.
- Yes
- No
Do you agree to complete the required consumer training and follow the SSP Guidelines? *
This also includes the annual file review process.
- Yes
- No
The above facts are true and complete to the best of my knowledge. I authorize Vancro to release my application information and personal profile to my SSPs in the event of an emergency. I authorize Vancro to send my personal profile to the appropriate state agencies for the purpose of evaluating the SSP Program.
Type applicant or guardian signature (if under 18 years old)
Preferred SSP(s)
- {name}
Ex. Usher Syndrome, CHARGE, Diabetes, Stroke, etc.
My pronouns are:
Ex. they/them, he/his, she/hers, etc.
- He/His
- they/them
- She/hers
- Other
Are you of Hispanic, Latino, or of Spanish origin?
- Yes
- No
How would you describe yourself? *
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or other Pacific Islander
- White
- Other
What is your Marital Status? *
- Single (never married)
- Married or in a domestic partnership
- Widowed
- Divorced
- Separated
What is the highest degree or level of school you have completed?
If you are currently enrolled in school, please indicate the highest degree you have received.
- Less than a high school diploma
- High school degree or equivalent (GED)
- Some college, no degree
- Associate Degree
- Bachelor's Degree
- Master's Degree
- Doctorate
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