KENTUCKY SCHOOL FOR THE BLIND

2015MS/HS SUMMER ENRICHMENT or WORK PROGRAM

STUDENT APPLICATION

Student Name: DOB:

Age: Male Female Grade completed 2014-2015:

Local School District: School Now Attending:

Parent E-mail Address:

Parent/Guardian Name:

Address:

StreetCityZip

Daytime Phone #: () Night Phone #: ()

Emergency Contact: ()

NameRelationship to StudentPhone #

Please list any medications your child/student takes:

Eye Condition: Visual Acuity:

Are there any restrictions and/or medical conditions we should be aware of? (seizures, diabetes, allergies, special diet, sunburns easily, requires one-on-one assistance, etc.)

Please explain: ______

  1. Is the student able to complete all toileting activities independently? Yes No
  2. Is the student able to eat and drink independently? Yes No
  3. Is the student able to dress independently? Yes No
  4. Is the student able to bathe independently? Yes No
  5. Will your child be staying for the weekend? Yes No
  6. Does your child/student receive services from a Teacher of the Visually Impaired? Yes No

If yes, please list Teacher’s Name:

  1. Is the student able to use intentional verbal language to communicate? Yes No
  2. Does the student require medical supervision during the day, evening or on field trips? Yes No
  3. Does the student require a special diet? Yes No
  4. Does the student exhibit behavioral issues (e.g., hit, bite, scratch, kick, etc.)?? Yes No
  5. Does the student require constant supervision because he/she may wander or run away? Yes No
  6. Does the student require constant supervision because he/she may harm self or others? Yes No
  7. Does your child/student receive Orientation & Mobility services? Yes No

If yes, please list Instructor’s Name: ______

  1. Does your child/student use a cane? Yes No
  2. Can the student independently navigate the environment, with or without a cane? Yes No

My child/student uses the following: Large Print Regular Print Braille Glasses

Contact Lenses Tapes Monocular Magnifier Cane CCTV

Assistive Technology (please specify):

Please indicate program attending:

Work (age 16 & up) ********** (Sunday, June 14 – Friday, June 26) ****************Activity Fee $100

MS/HS *************************(Sunday, June 14 – Friday, June 26) ****************Activity Fee $100

Note: Dorms: Priority will be given to students living more than 60 miles from KSB.

KSB does not provide transportation. Activity Fees include meals. Need based scholarships are available for families with more than one child attending. Please contact Allison Chandler, DoSE.

DEADLINE FOR APPLICATION: April 15, 2015

NOTE: Applications must be submitted with copy of current IEP and eye report.

Failure to meet the above deadline or applications not submitted with the required paperwork may result in the student not being accepted to the program.

All activity fees are nonrefundable.

MAIL TO: Allison Chandler, Kentucky School for the Blind, 1867 Frankfort Avenue, Louisville, KY 40206

Fax #: 502-897-2850, or e-mail to:

Please attach a letter to this application describing any special needs your child may have or anything that would help us know your child better.

Who completed this form?

Name: Title:

******************************************************************************************************************************

LOUISVILLE ZOO WORK PROGRAM APPLICANTS ONLY(must be 16 or older)

Do you have an Office for the Blind Counselor? Yes No

Name of OFB Counselor?

What is your career goal? ______

Do you have any previous work experience? Yes No

If so, please describe:

Do you have difficulty being outside in hot temperatures? Yes No

2 Letters of Reference attached? Yes No

  • Letters should be from teachers, school counselors, Office for the Blind counselors, or previous employers. Letters should address the student’s personal, social, and work attitude skills. We want to ensure that a student is ready for a full day of truly enriching but demanding work. Reference letters must be signed and include printed name and phone number of person writing referral. Students/referring parties will also be interviewed either face to face or by phone before selection.

Resume attached? Yes No

T-shirt size: Small Medium Large X-Large XXL Other: