VRCBVI 2026 LIFE Application
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The LIFE Program: Learn, Grow, and Have Fun!

It’s time to show what you can do! The LIFE Program is a 4-week, summer program where you will:
  • Learn new skills for living with blindness or low vision
  • Become more independent
  • Build confidence
  • Make friends with other teens who want to grow—like you
This program is more than training. It is your chance to feel confident, gain freedom, and take steps toward your future.

Check out: the pictures from 2025 LIFE Program and the VRCBVI YouTube Channel

 Apply for the 2026 LIFE Program (LIFE = Learning Independence, Feeling Empowered!)

Dear Student 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’re excited to help you to become more confident through:
  • Learning new skills
  • Working in the community (students 16 and older, if appropriate)
  • Enjoy fun evening and weekend activities

Who can apply?

You can apply if:
  • You can attend all 4 weeks (unless school starts early)
  • You are 14 to 18 years old and will return to high school in the fall of 2026
  • You must be 14 by July 12, 2026
    • ─ You must not turn 19 before August 7, 2026
  • You are blind or have low vision
  • You can learn in group classes and activities
    • ─ VRCBVI is unable to provide 1-1 instruction
  • You can take care of yourself, including your own medicine.
  • You have a state photo ID
  • You are willing to open (or already have) a Vocational Rehabilitation case with DBVI

What You Need to Send in Order to Complete the Application Process:
You will get the forms by email from Brooke Rogers within 2 business days. To apply, send all of the following by the deadline:

1) DBVI Health Checklist/Medical Exam
  • Completed by a doctor within one year of the deadline (April 28, 2026)
  • If you came to LIFE before and nothing has changed, we can use your old form. Let us know to use the report from last year.
2) DBVI Eye Exam Report
  • Completed by a doctor within one year of the deadline (April 28, 2026)
  • If you came to LIFE before and nothing has changed, we can use your old form. Let us know to use the report from last year.
3) A copy of your current IEP(Individualized Education Plan).

What Happens Next:
  • VRCBVI admin staff meet weekly to review all complete applications.
  • Once an admission decision is made, you will be notified.
  • We can only accept 22 students
  • If you are accepted, we will send you a Welcome Packet. It will include more forms for activities. This packet will be sent to the email address you listed in your application.

If You Cannot Attend

If you are accepted but cannot attend, please contact
Amy Phelps
804-371-3052
amy.phelps@dbvi.virginia.gov

This helps us offer your spot to another student.

Important Dates

Application Deadline: Tuesday, April 28, 2026. We cannot accept late applications
Program Dates:
  • Starts: Sunday, July 12, 2026, at 1:00 PM
  • Ends: Friday, August 7, 2026, at 12:00 PM (noon)
Attendance
  • Students must stay for all 4 weeks
  • If school starts early, you may leave during the last week
    • ─ Send us a note with your school start date
  • All students must take part in:
    ─ Weekday classes
    • ─ Evening activities
    ─ Saturday confidence-building activities

Work-Based Learning
  • Ages 16–18:
    • ─ You will work part-time in the community during the last 2 weeks
  • Some students may continue learning blindness skills instead of working
  • Ages 14–15:
    • ─ You will not work
    ─ You will attend full-day classes to learn skills like: ▪ Cane travel ▪ Braille ▪ Access Technology ▪ Cooking, cleaning, and organizing ▪ Wellness Instruction


Questions?
  • Application questions: Contact Brooke Rogers at (804) 371-3338, or brooke.rogers@dbvi.virginia.gov.
  • Program questions: Contact Amy Phelps at (804) 371-3052 or amy.phelps@dbvi.virginia.gov

    • We’re looking forward to another great summer and hope to hear from you soon!


    Amy Phelps, Assistant Director for Instruction
    Phone: (804) 371-3052
    Website: VRCBVI
    Required fields will be marked with **.

    Section 1: Let's Get to Know You!

    Student Information
    **Student’s First Name:
    **Student's Middle Initial:
    **Student's Last Name:
    **Student's current age:
    **Name of person who is completing this application:
    **Relationship to student applying:
    **Student’s mailing address (street address, city, state and zip code):
    **Student's physical address if different than above?
    **Student’s cell number. This is the number we will use if we need to reach the student during the program. (If the student does not have a cell phone, please enter N/A):
    **Student’s email address: (This is the email we will be use for communication during program. Please ensure it is the student's email, not the parent's. If the student does not have an email, enter N/A.)
    **Date of birth:
    **Grade ('26-'27 academic year):
    **Expected Graduation Year:
    **Name of current school and location:
    **DBVI Vocational Rehabilitation Counselor name (enter N/A if unknown):
    **DBVI Education Coordinator name (enter N/A if unknown):
    ** Teacher for the Vision Impaired name (enter N/A if unknown):
    **Has the student ever gone to a summer blindness skills training program outside the LIFE program? If yes, please list below. If no, please enter No.
    ** What does the student enjoy doing in their free time?
    Career pathways
    ** What kind of jobs or careers is the student interested in?
    What kind of work and/or volunteer work have you done in the past?
    Success Tools:
    Student accommodations
    ** Do you need any of the the following student accommodations?
    **Please provide details about the requested accommodations or enter NA:
    ** Does the student have any concerns about getting used to being blind? (For example: Are they new to being blind or having trouble with everyday tasks like getting dressed, cooking, or walking by themselves?)":
    Section 2: Student Medical Information

    Your health and safety are very important to us. We need some medical information to review as part of the application process.
    Medical Insurance


    ** Please write the name of the student's medical insurance provider and the policy number. (If none, write N/A)

    Note: Student will need to bring a copy of their insurance card. This helps us in case your student needs medical care or has an emergency.
    Vision Information

    ** Cause of blindness/vision loss, if unknown, enter unknown:
    **Visual acuity, if unknown, enter unknown:
    **Field of vision, if unknown, enter unknown:
    Medical Diagnoses
    Medical Diagnoses
    **If your student has any of the health conditions below, please check all the ones that apply.
    Additional Health Information
    Please use the space below to:
    • Share more details about any health conditions you checked earlier
    • Describe any other health conditions your student has that were not listed
    This helps us to better understand your student's needs and how to support them during the program.
    ** Does the student have diabetes?
    Diabetes plan
    If yes, please check all the boxes that describe how your student manages their diabetes:
    If your student has a long-term health condition, do you already have a plan to help them manage it? If yes, please explain. (For example: needs to drink water often to prevent seizures, uses an inhaler when active, or needs a quiet room to rest during migraines.)
    ** Does your student need to follow a special diet prescribed by a doctor, like a kidney-friendly diet or a gluten-free diet for celiac disease?
    If yes, please describe the dietary needs as provided by the student's doctor:
    ** Are there any emotional or mental challenges that make it hard for the student to stay in control or take care of daily needs??
    If yes, please describe and explain how your student manages these needs:
    ** Can the student actively participate and learn in group settings?
    **If no, please explain or enter NA:
    ** Does the student have any physical limitations or activity restrictions?
    If yes, please describe:
    **Medication and Allergies

    Please list any allergies your student has and describe the reaction for each. Include allergies to:
    • Medication
    • Insects (like bee stings)
    • Environmental factors (like pollen or dust)
    • Foods (like peanuts, dairy, etc.)
    Examples of reactions: trouble breathing, swelling, severe skill rash, etc.

    If your student has no known allergies, enter N/A.
    Epinephrine (EpiPen) Use for Allergies

    Does student's allergy require an EpiPen?

    If yes:
    • Your student will need to bring their EpiPen with them
    • Your student must be able to use the EpiPen without supervisor
    **List all prescription and over-the-counter medications student is currently taking including:
    • Dosage
    • Time(s) taken
    • Reason for taking
    • Medications taken by mouth, injection, or inhaled.
    (If the student takes no prescription or over-the-counter medications enter N/A):
    Medication Management Plan
    **VRCBVI uses an empowerment model of training and does not have any medical staff. The LIFE program promotes independence, so:
    • Students must manage all prescriptions and over-the-counter medications
    • VRCBVI staff cannot administer or store prescription or over-the-counter medications.
    Please select the option that best describes your student’s medication management plan while attending the LIFE program:
    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. Be sure to include medication for headaches, cold/allergy symptoms, cramps, and commonly occurring aches and pains (VRCBVI does not provide or administer)
    2. Student will bring enough medication for the entire length of the residential 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, incontinence supplies, cpap machine, walker, etc.
    4. Student will bring all needed personal hygiene supplies
    5. Student will bring their medical insurance card(s) if applicable
    Self-care acknowledgement
    ** Self-care acknowledgement:
    Section 3: Parent or Guardian Contact Information
    To help us communicate clearly with families, please provide Parent/Guardian name and preferred language for communication.
    ** Parent/Legal Guardian #1 Name:
    **Address:
    **Primary Phone Number:
    **Email Address:
    Parent/Legal Guardian #2 (if applicable)
    Name:
    Phone number:
    Parent/ Address, if different from above:
    Email address:
    Are you the student's legal guardian?
    If yes, please fax or email a copy of the legal guardianship court order to:
    VRCBVI, Attention: Brooke Rogers
    Fax: (804) 371-3092
    Email: brooke.rogers@dbvi.virginia.gov.

    If no, please explain:
    If parents have an order granting them legal custody of the student, please fax or email a copy of the court order to:
    VRCBVI, Attention: Brooke Rogers
    Fax: (804) 371-3092
    Email: brooke.rogers@dbvi.virginia.gov.

    If no, please explain:

    If the student’s parents have joint custody of the student, all forms and documentation pertaining to LIFE 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):
    Emergency Contact Information
    ** Emergency contact name, phone number, and relationship to student:
    ** Emergency contact address:
    **If the student is dismissed from VRCBVI residential program or during any emergency closing, the student must be picked up within 8 hours and will return to the following address:
    Section 4: Releases and Waivers

    **Virginia Rehabilitation Center for the Blind and Vision Impaired
    401 Azalea Ave., Richmond VA 23227
    Office (804) 371-3151
    https://www.vrcbvi.virginia.gov/

    RISK AND INDEMNITY AGREEMENT
    By taking part in activities sponsored by VRCBVI, I confirm that I understand what the activity involves. I confirm I am healthy and able to take part. If at any point I feel the activity is unsafe, I will stop right away.

    I understand that joining in this activity comes with risks. These risks could include serious injury, permanent disability, or even death, as well as damage to personal property. These risks may be caused by my actions, the actions of others, the environment, or accidents that no one can predict. I accept all these risks and take full responsibility for anything that happens because of my participation.

    By signing this form, I agree not to sue DBVI, its staff, volunteers, or anyone else involved in the activity. This includes any injuries or damages that may happen, even if they are caused by someone else’s mistake. If I or someone else tries to make a claim, I agree to pay for any costs that come from it.

    I have read and understand this agreement. I am signing it voluntarily and intend it to be a full release of liability. If any part of this agreement is found to be invalid, the rest will still apply. This agreement is valid from November 2025 through December 2026.



    Parental Consent and Release of Liability (For Students Under 18)


    If your student is under 18 years old, a parent or legal guardian must complete this section.

    By signing below, I give permission for my child to take part in the LIFE program at VRCBVI. I understand that this program is designed to help students become more independent. I also understand there are no medical staff on site. My child must be able to take care of their own medications and health needs while attending.

    I understand that taking part in this program may involve some risks. These risks could include injury, illness, or damage to personal items. I accept these risks and agree that my child is able to take part in the program.

    I agree not to sue VRCBVI, DBVI, or any of their staff or volunteers if something goes wrong. If someone tries to make a claim because of my child’s participation, I agree to pay for any costs that come from it.

    I have read and understand this agreement. I am signing it freely and agree to all the terms.


    **Please select yes or no if you agree to the above.
    **Participant - write your signature by typing in your full name.
    **For students under the age of 18 -
    Custodial Parent/Legal Guardian Signature Participant - write your signature by typing in your full name:

    **VRCBVI 2026 LIFE Program Student Learning Agreement

    To help students have a safe, fun, and successful summer, we’ve created a list of expectations. Please review this list together with your student before arriving at VRCBVI.

    While attending the LIFE program, students will:
    • Unpack and organize their belongings with help from their mentor.
    • Wash their own clothes and keep their dorm room clean.
    • Never leave campus without an approved adult.
    • Always check out with staff before leaving campus.
    • Tell their Center Case Manager (Kris Foley) or Administration if they have any problems or concerns.
    • Treat all students and staff with respect.
    • Only hang out with other students in approved common areas.
    • Use their cane at all times.
    • Wear learning shades during some classes and evening and weekend activities.
      • *See note below regarding the use of learning shades as a teaching tool.
    • Not use cell phones during class or planned activities.
    • Not share other students’ contact information without permission.
    • Not use or have drugs, alcohol, or marijuana in any form.
    • Not use or have weapons of any kind.
    • Take part in all parts of the program, including evening and weekend activities.
    *NOTE Students will sometimes wear learning shades (blindfolds) during classes and activities. These are used as a teaching tool to help students:
    • Learn new ways to do things without using vision.
    • Use other senses like touch and hearing.
    • Build confidence and independence.
    • Understand that vision is not the only way to succeed.
    • Learning shades help students become more independent and confident in their abilities.

    We have read and understand the expectations above. We agree to follow them during the LIFE program.

    Please sign below to certify that you have read and understand the student expectations. Students under the age of 18 must have a parent or guardian signature. Further, please be aware that failure to follow these policies can result in expulsion from the program. Write your signature by typing in your full name.
    ** Participant - write your signature by typing in your full name.
    ** Custodial Parent/Guardian write your signature by typing in your full name.
    ** Photographic Release

    I give permission to the Department for the Blind and Vision Impaired, and its employees, to use any photos or recordings of me or my voice. DBVI can use my photo and recording in any manner for advertising and publicity. DBVI may use my picture, video recording or voice recordings,
    • On DBVI’s website and other social media sites
    • In television, print products, or other media
    • To provide information to the public about DBVI
    • To educate and train
    I give permission for these photos or recordings to be reproduced, changed, or combined with other photos or recordings, or used in any media. By signing this form, I have read this and understand what it says.
    ** Student write your signature by typing in your full name.
    ** Custodial Parent/Guardian write your signature by typing in your full name.
    **Date signed:
    Before You Submit:
    • Double check phone numbers and email addresses.

      • If not correct, you will not receive the email with next steps

    • After you submit the application, you will see a blue screen.
    This means your application was successfully submitted.