A Short Course Program for Middle and High School Students

Saturday, January 23, 2016

Location: The Maryland School for the Blind

10AM to 3 PM

Course Description: This is a great time of year to think about developing some new and healthier habits! Students will participate in activities that can help improve focus, sleep, balance, flexibility and fitness as well as increase body and spatial awareness. Instruction will include basic dance routines, exercise and fitness routines, and adapted yoga techniques that, In addition to physical health benefits, can also help students to better manage feelings and improve coping skills. Students will prepare a nutritious lunch and dessert while learning about healthy food choices through fun games and discussion. All activities will be taught by highly qualified and/or certified staff including: Susan Vanderhoff,LCSW-C and Certified Yoga Instructor, Heather Browne, Experienced Dancer, Matt Mescall, Adaptive PE Teacher, and Genelle Hughes, Low Vision Rehabilitation Specialist.

If you have any questions about the registration process, please contact Vicky Watt at 410-444-5000, ext. 1249. Fax: 410-319-5708 COST: $10.00 per Student

Ruth Ann Hynson, Director of Statewide Outreach Services

The Maryland School for the Blind ~ Outreach Dept.

3501 Taylor Avenue, Baltimore, MD 21236

Baltimore, MD 21236

Short Course Program - A New Year and New You!

Registration

PARTICIPANT INFORMATION:
Student: ______DOB: ______
Grade: ______School: ______
Parent(s): ______
Address:______City:______State:____ Zip:______
County: ______Vision Teacher: ______
Home Phone: ______Cell Phone: ______
Email: ______Siblings: ______
VISUAL INFORMATION (Students are required to bring portable low vision or Braille devices and canes):
Eye Condition:______
Level of Vision: ___ Totally Blind ___ Partially Sighted ___ Legally Blind ___ Wears Glasses
Field Loss: ___ Yes ___ No
Child uses the following for learning: ___ Regular Print ___ Large Print ____ Braille ___ Auditory Skills
Travel Skills: ___Independent ___Needs Supervision ___Uses Cane ___Prefers Sighted Guide
ADDITIONAL INFORMATION:
Other Disabilities: ______
Medications your child currently takes: ______
______
Allergies:
Medication (describe) ______
Food (describe) ______
Environmental (describe)______

RELEASE STATEMENTS:

Photo Release: Many pictures are taken during the programs of various activities. These pictures are sometimes used, along with press releases, to provide public relations information to television stations, newspapers and other publications. I grant permission for my family to be photographed for the above purposes.

___ Yes ___ No

Please note: Wear comfortable clothing and tennis shoes, this program requires physical activity.

Please fax or mail registration to:

The Maryland School for the Blind

Outreach Department

3501 Taylor Avenue

Baltimore, MD 21236

ATTN: Victoria Watt

Phone: 410-444-5000 ext. 1249 FAX: 410-319-5708

Email:

The Maryland School for the Blind

PHYSICAL ACTIVITY FORM

School Year 2015-2016

*If you completed this form during the summer program you will not need to duplicate.

Student Name: Date of Birth:

Adapted Physical Education- All students have Adapted Physical Education as part of their curriculum. Please indicate below if there are any medical reasons for exception.

Adapted Physical Education

(Example: Age appropriate skill development, fitness & activities) No exception

Exception:

Adapted Aquatics: goggles required for students with M.D. orders No exception

Exception:

Adapted Recreation (Example: Skiing, Bowling, Horseback Riding)  No exception

Exception:

Physician’s SignatureDatePhysician Phone Number

Parent/Guardian SignatureDate

CD/LB/cic:4/1/14