Home » BALANCE services » Application for BALANCE for Blind Adults Services

Application for Services

Personal Information

• Name
• Address
• Apartment Number
• City
• Province
• Postal Code
• Entry Code, if applicable
• Telephone number
• Email Address

Citizenship

I am a Canadian citizen
I am a Landed Immigrant
I am a Refugee
I have other citizenship
If you selected “I have other citizenship” please explain

How did you find out about BALANCE?

I found out about BALANCE through the C.N.I.B.
I found out about BALANCE through a website or search engine
I found out about BALANCE through a BALANCE program participant
I found out about BALANCE another way
If you selected “I found out about BALANCE another way” please explain

Services

I would like Access Technology Training
I would like Community Access Facilitation / Housing services
I would like Daily Living Skills training
I would like Employment Services. Please also complete the application for Employment Services.
I would like Orientation and Mobility training

Have you received any of these services from another agency?

I have received these services from another agency
I have not received these services from another agency

If you have received these services from another agency, in which areas did you receive instruction?

Are you legally blind?

I am legally blind
I am not legally blind

Which best describes your vision?

I am totally blind
I have low vision

Education

I am in school
I am not in school

Are you currently employed?

I am employed
I am not employed

The Program Coordinator will contact you on receipt of your application.

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Privacy of Information

BALANCE for BLIND ADULTS respects the privacy of each individual. BALANCE collects only limited identifiable personal information and never releases this information without the written permission of the individual.

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Contact Us

Email:	Click the submit button above or
Fax:	416-236-4280 or
Mail:	BALANCE for Blind Adults 4920 Dundas St West Suite 302 Toronto, ON M9A 1B7

If you need assistance completing this form
please contact BALANCE at (416) 236-1796