Success Story (This form is voluntary) I authorize DRS to use this information to educate the public, Oklahoma legislators, US Congress members and/or the media about DRS services and my success. I hereby release Oklahoma DRS, partner agencies and authorized agents from liability or claims arising out of the use of my name, photo or video and the information provided on this form. By submitting this form online I give permission to use the information without a signature signed with an ink pen. Permission * Yes, I give permission No, I do not give permission Name-disabilty Name * Name * Disability Type Disability Type Phone Phone E-mail E-mail Mailing Address Mailing Address DRS services provided (check all that apply) Training/Education Counseling and Guidance Physical Restoration Telecommunications and Adaptive Equipment Job Placement Information and Referral Transition Independent Living Services Library for the Blind Services Other (please list) DRS services provided (check all that apply) Other (please list) Who provided your services? Which division did you receive services from: Vocational Rehabilitation Services for the Blind and Visually Impaired Oklahoma School for the Blind Oklahoma School for the Deaf Oklahoma Library for the Blind and Physically Handicapped VR Sevices Services for Deaf or Hard of Hearing Adult Career Services Transition Services SBVI Services Older Blind Adult Career Services Business Enterprise Services Transition Services Legislators I would be willing to talk with my legislators about my experience with DRS. I give my permission for DRS to give a copy of this form to my legislator. Your story Share your success story about how DRS has helped you: (Compare your situation before and after DRS: newly acquired job or return to work, educational experience, assistive technology solution, funding assistance, greater independence in the home or the classroom) Submitting this form indicates that you give permission to use the information without a signature. If parent/guardian/authorized representative filling this out, name: Leave this field blank DRS-C-201 Revised 12/13/2023
