Page 1 of 8

Student

First Name

Last Name

Student Birthdate

ex: 1/2/2005

Gender

Student Phone

###-###-####

Student Email

Email must be different for each individual listed on application

Street Address

City

Country Of Citizenship

State

Zip/Postal Code

*To add additional contacts use the Add Another Contact link below the first contact

Family Contacts

Relation to Student

Resides with the applicant?

First Name

Last Name

Email

must be unique for each contact

Phone number

ex: ###-###-####

Street Address

(If different than applicant)

City

(If different than applicant)

Country Of Citizenship

State

(if different than applicant)

Zip/Postal Code

(If different than applicant)

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Student Educational Information

Current School

Please explain other

Current Grade

Anticipated Year of Graduation

Dates of attendance at current school

ex: 1/2/2005

Name of Teacher of the Visually Impaired

Email of Teacher of the Visually Impaired

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Short Answers About Your Student

We want to get to know about your student and their interests, plans, and goals. Please complete these questions.

What does your student enjoy about school? Please share details about your student's general academic interests

What are your student's preferred activities outside of school? Please include activities and interests they enjoy, such as music, art, physical fitness and/or meaningful family activities and commitments.

Does your student have a modified curriculum? (i.e. reduced work, output, adjusted test questions, etc.)

What top three skills do you believe your student needs to develop in order to be ready for life after high school? Please explain.

Have you discussed post secondary plans with your student? Have any Educational team members been part of these discussions? (i.e. TVI, Special Ed team, or Transition Counselor) Please share specifics.

In what areas do you see your child's strengths as they anticipate college and independence? In what ways are you concerned, or feel that he's unprepared? What areas do you feel unprepared? Consider these skills as you answer this question: (Advocacy, O&M, Executive Functioning, Social Skills, etc)

When thinking about your student’s post secondary journey, where do you feel there is highest need for growth? Consider these skills as you answer this question: (Advocacy, O&M, Executive Functioning, Social Skills, etc)

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Vision

Please describe your student’s visual diagnosis, including age of onset, and age of start of services.

Please describe ways that your child's vision impairment currently impacts activities of daily life, and academic functioning.

Please list any additional disabilities including learning differences.

To what extent does your student understand their visual impairment and its implications on their life and learning?

Reading and Writing

What is your student’s current reading level? If unknown, we encourage you to have this discussion with your student’s educational team.

At this time, what is your student's preferred reading method?

On which device does your student read?

What is their reading rate on their preferred reading method? If unknown, we encourage you to have this discussion with your student’s educational team.

What is their preferred writing method?

What is their typing speed? If unknown, we encourage you to have this discussion with your student’s educational team.

Where is homework completed?

Homework assistance level

How much time do they spend on homework per week?

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Technology

Is the student independent in their use of technology?

Describe the assistive technology that your student currently uses for academic work, including screen readers, braille notetakers, magnifiers, and any other technology used on a regular basis.

When were these devices introduced? Does your student receive specific training outside of school?

Describe any other technology currently used, such as a laptop, iDevice, etc.

Orientation & Mobility

Describe your student's orientation & mobility, at school, home and in the community, including navigation strengths and developing skills. Please describe their use of mobility aids including the use of a white cane, guide dog, walker, wheelchair, or other tools.

How many hours of mobility training is your student currently receiving? If none, when did it conclude?

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The next three sections: Daily Living Skills, Social Skills and Organization Skills contain questions with radio button responses. If using a screen reader, please be advised you may need to turn off the virtual cursor before tabbing through the form to mark the appropriate radio button for each question.

Daily Living Skills

	Not Attempted	Require Support	Independent
Doing Laundry
Caring for personal hygiene (bathing, hair care , brushing teeth, etc. )
Self-administration of medications
Maintaining a clean environment
Choosing what to wear
Preparing simple meals
Shopping for wants/needs
Managing money

Social Skills

	Not Developed	Developing	Strong
Making new friends
Getting along with others
Reading other people's emotions
Taking turns in conversation
Engaging with others
Being part of a team
Communicating wants and needs to peers
Being a leader
Communicating wants and needs to older adults

Organization Skills

	Not Developed	Developing	Strong
Using a planner or track list
Finishing assignments on time
Breaking down large tasks into manageable steps
Staying focused
Avoiding procrastination
Using time wisely
Keeping electronic and/or print materials organized
Keeping track of belongings
Maintaining a clean space (desk,locker,bedroom)

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Medical and Mental Health

Describe mental health concerns, including specific diagnoses, ongoing counseling needs, medications, and/or past hospitalizations that we should be aware of. (minimum 25 words)

Person Who Is Completing the Application

Person completing this form

Please explain other

How did you hear about us?

Please explain other

Word of mouth via

If you received assistance completing this form, please explain. (minimum 10 words)

If the student completed this application, what level of assistance did you give them (if any)? (minimum 10 words)

First Name

Last Name

Email

Phone number

ex: ###-###-####

Organization Name

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Required Application Documents

Submit application materials here or by mail, email, or fax. File types that can be uploaded:

.doc (Older Microsoft Word format)
.docx (Current Microsoft Word format)
.pdf (Adobe PDF)
.odt (Open Office word processor document)

If you have any questions about this, please contact the Admission Office.

Transcript

Please attach or upload unofficial transcripts from all schools attended, Grade 9-current.

Supplemental Application Materials

Individual Education Plan (IEP)

Standardized testing (SAT/ACT)

Educational, Psychological/Neuropsychological, and Speech and Language Evaluations (preferred but not required)

Optional Additional Application Materials

Upload Medical Documentation

Please share any additional information that will help us to get to know your student

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