2017 SKILLS- Vancouver APPLICATION

2017 SKILLS- Vancouver APPLICATION

Monday, July 24 through Friday, July 28, 2017

PERSONAL INFORMATION

Student Name:

Address:______City/Zip:______

Mail Address: ______

Date of Birth: ______

Gender: ☐Female☐MalePhone Number:

Social Security Number ______- ____ - ______☐ not applicable

*Note: if emailing SKILLS application, do NOT electronically transmit SSN. Instead, call Marcie Ebarb’sconfidential voice mail at (360) 947-3286 and leave full SSN.

Student has ☐IEP ☐ 504 Plan

Race: ______Ethnicity: ______

Parent or Guardian - #1

Name: ______

Address :( Street) ______

(City)______(State) ______(Zip) ______

(If different from student address)

Phone: ______Email: ______

Parent or Guardian - #2

Name: ______

Address:(Street) ______

(City)______(State)______(Zip) ______

(If different from student address)

Phone: ______Email ______

Name of school: ______

Vision Teacher Name:

Phone number: ______Email: ______

Orientation and Mobility Specialist Name: ______

Phone number: ______Email: ______

EMERGENCY CONTACT PHONE NUMBERS

Contact #1 Name: ______

Home #: ______Cell #:______

Work #: ______

Contact #2 Name: ______

Home #:______Cell #:______

Work #: ______

MEDICAL/SPECIAL NEEDS INFORMATION

To insure the safety and wellbeing of all students, please provide full disclosure to the following questions. Lack of disclosure or incomplete information regarding medical, behavioral or emotional issues that could potentially interfere with a student’s participation in program objectives, or that could affect the safety and wellbeing of camp participants and staff, will be grounds for termination from Camp.

Please answer the following questions so we are able to better plan for a safe appropriate and fun experience for all.

Please define the student’s visual impairment and diagnosis______

☐Legally Blind ☐Totally Blind ☐Visually Impaired

Other Disabilities (if any):______

______

Please describe any medical, emotional and/or psychological considerations/conditions and list current medications (if any):

Does the student eat independently? ☐Yes ☐ No

Comments: (please describe any dietary restrictions /food allergies, etc.) ______

Does the student use any mobilitydevices/accommodations(other than a long white cane) (examples: wheelchair, walker, interpreter, etc.) ☐No ☐Yes, the student uses______

Does the student travel independently in familiar environments? ☐Yes ☐ No

Comments: ______

Does the student toilet independently? ☐Yes ☐ No

Comments: ______

Does the student read at or near grade level? ☐Yes ☐ No

What is the student’s reading and writing medium?

☐Braille ☐ Large Print ☐ Regular Print ☐ Nonreader

Please return this application

No later than May 31, 2017

To:

Marcie Ebarb

Washington State School for the Blind

2214 E 13th Street

Vancouver WA 98661