2020 VRCBVI and University of Richmond STEPS to Success Application
Virginia Rehabilitation Center for the Blind and Vision Impaired Live the Life You've Imagined logo
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Student Information
Student’s Name:
Grade (Fall 2021):
Date of birth (mm/dd/yyyy):
Mailing Address:
Physical Address (if different from mailing address):
Student’s cell number. Enter NA if students does not have a cell phone:
Student’s email address. (Student must have working email address for STEPS to Success program):
Cause of blindness:
Visual acuity:
Field of vision:
Describe any adjustment to blindness issues:
Parent / Guardian Information
Parent/Legal Guardian Name(s):
Parent/Legal Guardian Address:
Parent/Legal Guardian name and phone number (#1):
Parent/Legal Guardian name and phone number (#2):
Parent/Legal Guardian name and phone (Home):
Parent/Legal Guardian name and phone (Work):
Best time of day to contact:
Best person/ number to contact (cell, home or work):
Parent/Legal Guardian name and email address:
Student Medical Information
Name and phone number of student's primary care physician:
Does the student have other disabilities in addition to blindness?
If yes, list other disabilities here:
Does the student have any psychological or emotional disabilities?
If yes, briefly describe the psychological and/ or emotional issues:
Does the student have any physical limitations or activity restrictions?
If yes, briefly describe physical limitations or activity restrictions:
Does the student have diabetes?
If yes, please check all that apply about the student's diabetes management plan:
Does the student have any other chronic medical condition(s) that require a management plan, such as asthma, migraine disorder, seizure disorder, anxiety, etc.?
If yes, please list the chronic medical diagnosis and the established prevention plan (such as: uses an inhaler with exertion, requires extra time to orient to new situations, requires rest in a quiet room when experiencing migraine symptoms, needs to stay hydrated to prevent seizures, etc):
If needed, please list any further medical information here (such as: student currently has a foot ulcer that is healing, student will need to come home for a needed medical appointment during STEPS to Success, etc.)
List all of the student's medication allergies, food allergies and environmental allergies, including the allergic response (i.e. trouble breathing, rash). If no known allergies, type N/A.
List all prescription and over-the-counter medications student is currently taking, including the dosage, the time of administration, and the reason for the medication (if student takes no medications write N/A):
Medication Management Plan
VRCBVI staff cannot administer any prescription or over-the-counter medications. Instead, the student must self-administer all medications. Please describe the medication management plan for the student while attending the STEPS to Success program (select all that apply):
If needed, please list any additional, pertinent information about student's medication administration here:
Please choose "yes" to indicate that you understand and agree to the following:

1. student will bring all prescription and over-the-counter medications in the original bottle or container, taking into consideration headaches, cold/allergy symptoms and commonly occurring aches and pains
2. student will bring enough medication for the entire length of the STEPS to Success program, or will have a plan established to ensure student receives any needed refills
3. student will bring all needed medical supplies, such as diabetes supplies, cpap machine, walker, etc.
Does the student have any medically-prescribed dietary needs, such as renal diet, celiac diet?
If yes, please describe any dietary needs below:
Are special accommodations needed in the dormitory?
If you selected a special accommodation above, please describe what accommodations are needed:
Does the student have an open case with the Virginia Department for the Blind and Vision Impaired (DBVI)?
If yes, please provide the rehabilitation counselor’s or education coordinator’s name here:
What are the student’s goals for attending the STEPS to Success program?
Is there anything else the student wants the VRCBVI and the University of Richmond staff to know?
Emergency Contact Information
Emergency contact name, phone number and relationship to student (not provided above):
Emergency contact address:
If the student is dismissed from VRCBVI or during any emergency closing, the student must be picked up within 8 hours and will return to the following address (if different from student address as provided above):
If you are student’s legal guardian, do you have a copy of the court documents demonstrating that?
If yes, please fax a copy of the legal guardianship court order to VRCBVI, Attention: Brooke Rogers at (804) 371-3092.

If no, please explain:
If the parents have joint custody, please fax the court custodial order to VRCBVI, Attention: Brooke Rogers at (804) 371-3092.

If the student’s parents have joint custody of the student, all forms and documentation pertaining to the STEPS to Success program must be signed by both parents.
______ and ______ have joint legal custody of student. (please provide names)
I have sole legal custody of applicant (please provide name):
Signatures
Please sign below to certify that you have read, understand and agree with the student expectations. Failure to follow these policies can result in dismissal from the program.
Student Signature:
Custodial Parent/Guardian Signature: