2017 SKILLS- Vancouver APPLICATION
Monday, July 24 through Friday, July 28, 2017
PERSONAL INFORMATION
Student Name:
Address: City/Zip:
E Mail Address:
Date of Birth: Click or tap to enter a date.
Gender: ☐Female ☐ Male Phone Number:
Social Security Number - - ☐ not applicable
*Note: if emailing SKILLS application, do NOT electronically transmit SSN. Instead, call Marcie Ebarb’s confidential 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 #1 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 mobility devices/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
or
Sponsored by:
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