VRCBVI Application - 2018 LIFE Program

VRCBVI Application - 2018 LIFE Program (“Learning Independence, Feeling Empowered!”) Dear LIFE 2018 Applicant and Family: Thank you for your interest in the LIFE summer program at the Virginia Rehabilitation Center for the Blind and Vision Impaired (“VRCBVI”). We are excited to offer an interactive blindness skills training program, a real-world work experience, and vibrant confidence building activities this summer. Requirements to participate in the 2018 LIFE Program: If you meet the following requirements, please complete and submit the application packet to VRCBVI. By submitting an application, you acknowledge that you meet all required criteria. Applicants must: • Be between the ages of 14-18 and returning to a high school academic program in the fall of 2018 • Be blind or vision impaired and interested in acquiring blindness skills • Be able to actively participate in all five weeks of the program • Be able to participate in a group structured program • Be able to take care of personal care needs independently, including managing and self-administering medications • Have a valid government issued photo ID Application Check List: All applications must include the following documents: (Incomplete applications will be returned, but may be resubmitted when complete prior to the deadline) • VRCBVI 2018 LIFE application form (see below). • DBVI health checklist/general medical form completed by a medical professional and dated no more than one year prior to the LIFE application submission date. If a student attended a summer program at VRCBVI in 2017, the health form submitted for that program is acceptable, provided the parent(s) submit a statement that the student’s 2017 health information has not changed and the form is still accurate. • eye report form completed by a medical professional and dated no more than one year prior to the LIFE application submission date • a copy of the student’s most current IEP Acceptance Status: After the application deadline, all applications will be reviewed and interviews will be conducted. All applicants will be notified by May 15, 2018 of their acceptance status. If the applicant is accepted into the 2018 LIFE program, we will send you liability waiver and activity forms that you will be required to sign and return to VRCBVI prior to the program start date, July 8, 2018 in order for the applicant to participate in the program. If, after the applicant has been accepted into the 2018 LIFE program, he/she decides to cancel participation, please contact Greg Chittum at 804-371-3151 or greg.chittum@dbvi.virginia.gov so that students who are on the waiting list can be scheduled. Important Information to Remember: Deadline for Application: April 6, 2018. NO APPLICATIONS FOR THE 2018 LIFE PROGRAM WILL BE ACCEPTED AFTER THIS DATE. Dates of Program: The five week program begins Sunday, July 8, 2018, and will end on Friday, August 10, 2018, at noon. Attendance Requirements: Because this program is short and concentrated, we require that students who are accepted attend all five weeks. The only exception to this requirement is for students who are starting back to school during the last week of the LIFE program. If this is the case for the applicant, please attach documentation of when the student will be starting school. All students must participate in weekday classes and evening (6:00 p.m.-8:00/9:00 p.m.) and Saturday confidence building activities. Additional questions: Please refer to our flyer on our website, https://www.vrcbvi.org/YSprograms.htm, or contact Greg Chittum by phone at (804) 371-3151 or by email at Greg.Chittum@dbvi.virginia.gov. If you have questions about the application process, please contact Brooke Rogers, Assistant Director for Administration, at (804) 371-3151, or by email at Brooke.Rogers@dbvi.virginia.gov. We are looking forward to a great summer! Hope to see you soon! Greg Chittum, Coordinator for Community Engagement Virginia Rehabilitation Center for the Blind & Vision Impaired 401 Azalea Avenue Richmond, Virginia 23227 Phone: (804) 371-3151 Fax: (804) 371-3092 Facebook: VDBVI Website: https://www.vrcbvi.org/ YouTube: VRCBVI

LIFE 2018 Student Application

Student Information

Student’s Name: Student’s Name:

Grade (Fall 2018): Grade (Fall 2018):

Date of birth: Date of birth:

Mailing Address: Mailing Address:

Physical Address (if different from mailing address):Physical Address (if different from mailing address):

Student’s cell number: Student’s cell number:

Student’s email address:Student’s email address:

Cause of blindness:Cause of blindness:

Visual acuity: Visual acuity:

Field of vision: Field of vision:

Describe any adjustment to blindness issues:Describe any adjustment to blindness issues:

Has the student ever attended a summer training program? If so, please list the program(s) and date(s) of attendance. Has the student ever attended a summer training program?

Does the student have other disabilities in addition to blindness?

Does the student have other disabilities in addition to blindness?

Yes No

If yes, list other disabilities here: If yes, list other disabilities here:

Describe any medical, psychological, emotional, or physical limitations:Describe any medical, psychological, emotional, or physical limitations:

List all medications prescribed for the student:List all medications prescribed for the student:

Does the student have any allergies, e.g., food, medication, insects, etc.? If so, list here:Does the student have any allergies, e.g., food, medication, insects, etc.? If so, list here:

Does the student have any dietary needs, e.g., vegetarian, gluten free, other? If so, list here:Does the student have any dietary needs, e.g., vegetarian, gluten free, other? If so, list here:

Specify any special socialization needs:Specify any special socialization needs:

Are special accommodations needed in the dormitory? Please specify if required:

Are special accommodations needed in the dormitory? Please specify if required:

Adapted bathroom Deafblind accommodations Personal assistance aide Other (please specify below)

List other special accommodations needed here:List other special accommodations needed here:

Does the student have an open case with the Virginia Department for the Blind and Vision Impaired (DBVI)?

Does the student have an open case with the Virginia Department for the Blind and Vision Impaired (DBVI)?

Yes No

If yes, please provide the rehabilitation counselor’s or education coordinator’s name here:If yes, please provide the DBVI rehabilitation counselor’s or education coordinator’s name here:

What are the student’s goals for attending this program?What are the student’s goals for attending this program?

What does the student enjoy doing in his/her free time?What does the student enjoy doing in his/her free time?

Please list jobs the student would be interested in doing:Please list jobs the student would be interested in doing:

Does the student have any previous work experience?

Does the student have any previous work experience?

Yes No

If yes, list employer(s) and types of jobs performed.If yes, list employer(s) and types of jobs performed.

Is there anything else the student wants VRCBVI staff to know?Is there anything else the student wants VRCBVI staff to know?

Parent / Guardian Information

Parent/Legal Guardian Name(s):Parent/Legal Guardian Name(s):

Parent/Legal Guardian Address:Parent/Legal Guardian Address:

Parent/Legal Guardian Phone (Cell):Parent/Legal Guardian Phone (Cell):

Parent/Legal Guardian Phone (Home):Parent/Legal Guardian Phone (Home):

Parent/Legal Guardian Phone (Work):Parent/Legal Guardian Phone (Work):

Parent /Guardian email address:Parent /Guardian email address:

Best time of day to contact:Best time of day to contact:

Best number to contact (cell, home or work):Best number to contact (cell, home or work):

Name of parent/guardian we will be speaking with if we call:Name of parent/guardian we will be speaking with if we call:

Emergency contact name (other than parent/legal guardian):Emergency contact name (other than parent/legal guardian):

Emergency contact address:Emergency contact address:

Emergency contact phone:Emergency contact phone:

If the student is dismissed from VRCBVI or during any emergency closings, the student will return to the following address (if different from above):If the student is dismissed from VRCBVI or during any emergency closings, the student will return to the following address (if different from above):

If you are student’s legal guardian, do you have a copy of the court documents demonstrating that?

If you are student’s legal guardian, do you have a copy of the court documents demonstrating that?

Yes No

If yes, please fax a copy of the legal guardianship court order to VRCBVI at (804) 371-3092.

If no, please explain: 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 LIFE program must be signed by both parents.

Yes, I have sole custody of applicant (please provide name): Yes, I have sole custody of applicant (please provide name):

Yes, ______ and ______ have joint custody of student. (please provide names)Yes, ______ and ______ have joint custody of student.

Student’s Current Medical Providers

Name of Physician:Name of Physician:

Physician address: Physician address:

Physician phone: Physician phone:

Name of Ophthalmologist:Name of Ophthalmologist:

Ophthalmologist address:Ophthalmologist address:

Ophthalmologist phone:Ophthalmologist phone:

Signatures

Applicant’s Signature:Applicant’s Signature:

Custodial Parent/Guardian #1 Signature:Custodial Parent/Guardian #1 Signature:

Custodial Parent/Guardian #2 Signature:Custodial Parent/Guardian #2 Signature:

Student Learning Contract VRCBVI LIFE 2018 promises to be a worthwhile experience for students who take advantage of the opportunities offered. To maximize learning, we have identified expectations to ensure a safe, productive summer. We ask that parents and students review the following. Students will: 1. Never leave the facility without an adult (parent, approved family/friends, or staff). 2. Be responsible for telling the Center Case Manager or Administration about any problems. 3. Treat all students and staff with courtesy and respect. 4. Only gather with other students in approved common areas. 5. Use a cane at all times. 6. Understand that he or she will be using sleepshades as a learning tool during classes and occasionally during evening and weekend activities, as requested. 7. Not use cell phones during instructional times. 8. Not use tobacco products or illegal substances (drugs or alcohol). 9. Actively participate in all aspects of the program, including evening and weekend activities. 10. Exhibit behaviors that promote a positive learning environment free from bullying, threats, destruction of property or interference with the learning environment.

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:Student Signature:

Custodial Parent/Guardian Signature:Custodial Parent/Guardian Signature: