Tools for Independence Program

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Please complete the form below to register for an account. Once your account is registered and verified, you can request a free white cane or a slate and stylus.

Please note that the information provided on this form will be autofilled when you complete the Tools for Independence request form. If you have an address change, please remember to update your address in your profile settings.

Note: All fields with an asterisk * are required.

Personal Information

First Name

Last Name

Phone Number Format: 123-456-7890

Birth Date Format: MM/DD/YYYY

Address Information

Street Address

Address Line 2 (optional)

City

State

Zip Code

Account Information

Email Address

Confirm Email Address

Password Password must be at least 8 characters and contain: uppercase letter, lowercase letter, special character, and a number

Confirm Password