Interest Form BISM Work to Independence 2013
Blind Industries and Services of Maryland (BISM) Student Interest Form "Work To Independence 2013" June 22 - August 10, 2013
Please complete the interest form found below by April 1, 2013. Forms received after April 1 will be considered on a space avialable basis. Upon completion of the form, you will be contacted to set up time to talk over the phone. If you have questions or need assistance, please contact Dan Wenzel at (410) 737-2642 or dwenzel@bism.org.
Please Enter Applicant's Full Name
Year in School (fall 2013)
Date of Birth (mm/dd/yyyy)
Home Phone Number
Cell Phone Number
E-mail Address
Applicant's Street Address (Address where forms and information from BISM should be sent)
City
State
Zip Code
Name of Parent/Guardian (Mother)
Name of Parent/Gaurdian (Father)
Applicant lives with
Both Parents
Mother
Father
Relative or Gaurdian
Home Phone Number (Mother)
Mother's Cell Phone Number
Mother's Work Phone Number
Mother's Email Address
Best Time/Method to Contact Mother
Home Phone Number (Father- if different)
Father's Cell Phone Number
Father's Work Phone
Father's Email address
Best Time/Method to Contact Father
Name of Applicant's School
Name of Applicant's Teacher (TVI/TBS or O&M)
Applicant's Visual Acuity
Applicant's Cause of Blindness
Does the applicant have additional disabilities?
Yes
No
If yes, please describe additional disability/disabilities
Does the applicant have an open case with your state’s vocational rehabilitation program?
Yes
No
If yes, Name of Rehabilitation Counselor?
Rehabilitation Counselor's Phone Number
Rehabilitation Counselor's Email Address
Rehabilitation Counselor's Office Adress
Provide the names of adults who
are
authorized to pick up students during the program:
Provide names of the adults who
are not
authrozed to pick-up the studnt from the program:
If parent(s)/Gaurdian(s)are not availablee, who should we contact in case of emergency?
Relationship to applicant
Emergency Contact Primary Phone #
Emergency Contact Secondary Phone #
Has the applicant ever attended a summer program/camp?
Yes
No
If yes, please list program(s) and dates attended
Does the applicant have previous work experience?
Yes
No
If yes, please list work experience
Please list any career goal(s) or interest(s) of the applicant
What does the applicant wish to gain from attending this program?
What does the applicant enjoy doing on his\her free time?
Is there anything else which will help us to work more effectively with the applicant?