Student Application BISM Summer Independence Programs
Blind Industries and Services of Maryland Summer Independence Programs StudentApplication June 17 – August 10, 2012; Independence 101 July 22nd -- August 11, 2012
Please Enter Your Full Name
Year in School (fall 2012)
Name of School
Name of Teacher (TVI/TBS or O&M)
Birth Date (mm/dd/yyyy)
Street Address
City
State
zip
Home Phone Number
Cell Phone Number
E-mail Address
Parent's Home Phone Number
Parent's Cell Phone Number
Parent's Work Phone Number
Parent/guardian's E-mail Address
Best Time/Method to Contact Parent
Cause of Blindness
Visual Acuity
Do you have additional disabilities besides blindness?
Do you have an open case with your state’s vocational rehabilitation program? If yes, please provide the rehabilitation counselor’s full contact information, including name, phone number, and email address.
Have you ever attended a summer training program? If so, please list the name of the program program/date of attendance.
In which program are you interested?
Independence 2012
Independence 101
What do you wish to gain from attending this program?
What do you enjoy doing in your free time?
Is there anything else you would like to let the Independence staff know?