Sign Up for LightHouse Programs – LightHouse for the Blind and Visually Impaired

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 ^*

Primary Phone Type ^*

How did you hear about LightHouse?

If you can recall more specifically, please elaborate.

Mailing Address

Street Address ^*

City ^*

State ^*

Zip ^*

Country ^*

Emergency 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?* ^*

Level 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 of the conditions listed above affect the following:

Mobility? ^*

Cognition? ^*

Communication? ^*

Mental Health? ^*

Other? ^*

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? ^*

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 the questions below. If you choose not to disclose some of this information, simply select 'Declined' from among the drop-down options. 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) ^*

Gender ^*

Sex at birth ^*

Sexual orientation/Sexual identity ^*

If other, please specify.

Ethnicity ^*

Home language

Preferred language of communication with LightHouse ^*

Type of residence ^*

Number of people in household ^*

Monthly household income ^*

Are you a veteran?** ^*

Employment status ^*

Highest level of education completed ^*

Stay 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.

Referring 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.