VRCBVI 2026 LIFE Application
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The LIFE Program: Where Confidence Meets Adventure
It’s time to show the world what you can do, not what you cannot do! The LIFE Program is a 4-week, action-packed experience where you’ll learn new blindness skills, become more independent, build confidence, and make friends with teens who are ready to grow, just like you.

During LIFE you will:
Learn real-life skills for everyday living.
Make friends who understand your journey.
Discover how strong and capable you really are.

This isn’t just training—it’s your launchpad to freedom, confidence, and a future that’s 100% yours. Are you ready to take the leap?

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

 2026 LIFE “Learning Independence, Feeling Empowered!” Program Application

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 learn new skills, work in the community, and have fun with evening and weekend activities..

Who can apply?

You can apply if:

• You can attend all four weeks of the program (unless you need to go back to school).
• You are 14 to 18 years old and will go back to academic high school program in the fall of 2026. (You must be 14 by July 12, 2026, and cannot turn 19 before August 7, 2026.).
• You are blind or have low vision and want to learn new skills while having fun.
• You can learn in group classes and activities.
• You can take care of yourself, including your own medicine.
• You have a state ID with your photo.
• You are willing to open or already have a Vocational Rehabilitation case with DBVI.

What You Need to Send:
These forms will be emailed to you within 2 working days, from Brooke Rogers. These forms are necessary to complete the application process. We will only look at complete applications sent by the deadline:
1) DBVI Health Checklist/Medical Exam filled out by a doctor within one year of the deadline (April 28, 2026). If you were at LIFE before, you can use your old form if nothing has changed. Let us know to use the report from last year.
2) DBVI Eye Exam Report filled out by a doctor within one year of the deadline (April 28, 2026). If you were at LIFE before, you can use your old report if nothing has changed. Let us know to use the report from last year.
3) A copy of your current IEP (Individualized Education Plan).

What Happens Next: We will review complete applications after the deadline on April 28, 2026. We will let you know by Friday, May 8, 2026, if you are accepted. We can only take 22 students. If you are accepted, we will send you a Welcome Packet with additional forms which are needed in order to participate in activities with our approved vendors.

If you are accepted and cannot attend, please call Amy Phelps at 804-371-3052 or email amy.phelps@dbvi.virginia.gov so we can give your spot to someone else.

Important Dates:

Application Deadline: Tuesday, April 28, 2026. NO APPLICATIONS WILL BE ACCEPTED AFTER THIS DATE.

Program Dates: The program starts on Sunday, July 12, 2026, at 1:00 PM and ends on Friday, August 7, 2026, at noon.

Attendance: Students must stay for all four weeks. You can leave early if you have to return to school during the last week. If this is true, send us a note with your school start date. All students must participate in classes during the week, evening activities, and Saturday confidence building activities.

Work-Based Learning:
• Students aged 16 to 18 will work part-time in the community during the last two weeks.
• Some students may continue learning blindness skills (like cane travel, braille, access technology, and cooking) instead of working.
• Students aged 14 to 15 will not work. They will receive a full day of classes in learning the skills of blindness.

For questions about the application process, contact Brooke Rogers at (804) 371-3338, or brooke.rogers@dbvi.virginia.gov.
For questions about LIFE program, contact Amy Phelps at (804) 371-3052 or amy.phelps@dbvi.virginia.gov

We are excited about another great summer and hope to hear from you soon!

Looking forward to hearing from you!

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

Section 1: Let's Get to Know You!

Student Information
**Student’s mailing address (Please include street, 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 address we will use to communicate with the student during programs. Please ensure this is the student's email address and not the parent's - if the student does not have an email address, please 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 attended a summer blindness skills training program outside of 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 occupations or career pathways is the student interested in?
Describe any previous work and/or volunteer experience:
Success Tools:
Student accommodations
** Do you require the following student accommodations?
Please provide details regarding the requested accommodations:
** Describe any adjustment to blindness concerns (ex: Student is newly blind or experiences challenges with activities of daily living):
Section 2: Student Medical Information
Students health and safety are of utmost importance to us. We require medical information to be considered for the LIFE program.



** List Medical Insurance provider and policy number for medically necessary services and/or medical emergencies. Please have your student bring a copy of their insurance cards when participating in the residential programs. (If none, state N/A)
** Cause of blindness/vision loss, if unknown, enter unknown:
**Visual acuity, if unknown, enter unknown:
**Field of vision, if unknown, enter unknown:
Medical Diagnoses
**If the student has received any of the following diagnoses, please select all that apply:
Please provide any additional information regarding the above listed diagnoses and describe other conditions not listed above:
** Does the student have diabetes?
Diabetes plan
If yes, please check all that apply about the student's diabetes management plan:
If there is a chronic medical diagnosis, do you have an established management plan? If so, please explain. (Such as: needs to stay hydrated to prevent seizures, uses an inhaler with exertion, and requires rest in a quiet room when experiencing migraine symptoms, etc.):
** Does the student have any medically-prescribed dietary needs such as renal diet, celiac diet?
If yes, please describe any medically-prescribed dietary needs below:
** Does the student have any psychological or emotional differences that may affect their ability to self-care/self-regulate?
If yes, briefly describe the psychological and/ or emotional issues and provide information about how student self-regulates:
** Is the student able to actively participate/learn in group settings?
If no, please explain:
** Does the student have any physical limitations or activity restrictions?
If yes, please describe:
**Medication and Allergies
Please list any allergies and the reaction to each. Include allergies to medication, insects, environmental, and food (such as trouble breathing, severe skin rash, etc.). If no known allergies, enter N/A.
Does student's allergy require an epi pen? If yes, student will need to bring epi pen and be able to self-administer.
**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. Include any medications taken by mouth, injection, or inhaled. (If the student takes no medications enter N/A):
**VRCBVI uses an empowerment model of training and does not have any medical staff. Additionally, the focus of the LIFE program is to promote independence. Therefore, 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 LIFE program. Select from the list below:
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 / Guardian Information
** Parent/Legal Guardian #1 Name:
** Parent/Legal Guardian #1 Address:
** Parent/Legal Guardian #1 Primary Phone Number:
** Parent/Legal Guardian#1 email address:
To ensure effective communication with the parents or guardians of students accepted into the LIFE program, please provide below the name of the parent or guardian along with their preferred language for communication.
Parent/Legal Guardian #2 Name:
Parent/Legal Guardian Phone (Cell #2):
Parent/ Legal Guardian #2 address, if different from above:
Parent/Legal Guardian #2 email address:
If you are student’s legal guardian, do you have a copy of the court documents demonstrating that?
If yes, please fax or email a copy of the legal guardianship court order to VRCBVI, Attention: Brooke Rogers at (804) 371-3092 or brooke.rogers@dbvi.virginia.gov.

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 or brooke.rogers@dbvi.virginia.gov.

If the student’s parents have joint custody of the student, all forms and documentation pertaining to residential programs 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/

RELEASE, WAIVER OF LIABILITY, ASSUMPTION OF RISK,AND INDEMNITY AGREEMENT


In consideration of participation in the Virginia Rehabilitation Center for the Blind and Vision Impaired ("VRCBVI") sponsored activities, I represent that I understand the nature of the activity in which I am participating, and that I am qualified, in good health, and in proper physical condition to participate in such activity. I acknowledge and represent that if I believe activity conditions are unsafe, I immediately will discontinue participating in the activity.

I fully understand that this activity involves risks of serious injury, including but not limited to permanent disability, paralysis, and/or death, and damage to property, which may be caused by my own actions or inactions, the actions or inactions of others participating in the activity, the conditions in which the activity takes place or the negligence of the “Releasees” named below, and that there may be other risks not known or readily foreseeable at this time; and I fully accept and assume all such risks and all responsibility for losses, costs, and damages that I incur as a result of my participation in the activity.

In consideration of being allowed to participate in the activities, I hereby release, discharge, and covenant not to sue VRCBVI, its administrators, founders, directors, agents, officers, volunteers and employees, and other participants in the activity (each considered to be one of the “Releasees” herein) from any and all liability, claims, demands, and responsibility relating to injuries, death or damages to me or my property, which arise from or are caused or alleged to be caused by my participation in the activity, including claims, losses or damages caused or alleged to be caused, in whole or in part, by the negligence of the Releasees or otherwise, including negligent rescue operations. I further agree that if, despite this release, waiver of liability, and assumption of risk, I or anyone on my behalf, makes a claim against any of the Releasees, I will indemnify, save and hold harmless each of the Releasees from any loss, liability, damages or costs which any may incur as the result of any such claim.

I have read this Release, Waiver of Liability, Assumption of Risk, and Indemnity Agreement and have signed freely and without any inducement or assurance of any nature, intending it to be a complete and unconditional release of all liability to the greatest extent allowed by law. I agree that if any portion of this agreement is held to be invalid, the balance shall continue in full force and effect.


PARENTAL CONSENT

The below information applies to individuals who are under the age of 18 at the time of submitting this application and parent signature is required.

And I, the minor’s parent and/or legal guardian, understand the nature of the above-referenced activities and the minor’s experience and capabilities and believe the minor to be qualified to participate in such activities, I hereby release, discharge, covenant not to sue and agree to indemnify and save and hold harmless each of the releases from all liability, claims, demands, losses or damages on the minor’s account caused or alleged to have been caused in whole or in part by the negligence of the releases or otherwise, including negligent rescue operations, and further agree that if despite this release, I, the minor or one on the minor’s behalf make a claim against any of the above releases, I will indemnify, save and hold harmless each of the releases from any litigation expenses, attorney fees, loss, liability, damages or costs any release may incur as the result of any such claim.

**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 maximize learning, we have identified expectations to ensure a safe and productive summer. We ask that parents and students review this list together prior to arriving at VRCBVI. The expectations are as follows:

Students will:
1. Unpack and organize their personal belongings with the assistance of their mentor.
2. Be responsible for washing their own clothes and cleaning their dorm room.
3. Never leave campus without an approved adult.
4. Never leave campus without checking out with staff.
5. Be responsible for telling your Center Case Manager (Kris Foley) or Administration about any problems or concerns.
6. Treat all students and staff with respect.
7. Only gather with other students in approved common areas.
8. Use your cane at all times.
9. Wear learning shades occasionally during classes and during evening and weekend activities. *See note below regarding the use of learning shades as a teaching tool.
10. Not use cell phones during instructional times or during VRCBVI planned activities.
11. Not share their peers’ contact information without their permission. VRCBVI programs allow students to connect with their peers. We encourage networking.
12. Not use or possess drugs, alcohol, or marijuana in any form.
13. Not use or possess weapons of any kind.
14. Actively participate in all aspects of the program, including evening and weekend activities.

*Students will occasionally wear learning shades during classes, as well as during evening and weekend activities. Learning shades are an instructional tool designed to support the development of non-visual skills. By temporarily limiting their vision, students are encouraged to:
-- Develop alternative techniques that do not rely on vision which may not always be reliable.
-- Strengthen their use of other senses, such as touch, hearing, and spatial awareness.
-- Build confidence in their ability to perform tasks without depending on vision.
-- Understand that vision does not define success, and that independence and competence can be achieved through a variety of strategies.
-- The use of learning shades helps students internalize the idea that their abilities are not limited by their level of vision, and that mastering non-visual techniques can lead to greater independence and self-assurance.

Student and parent(s) have reviewed and agree to the Student Learning Agreement.

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.
** Virginia Department for the Blind and Vision Impaired Photographic/Recording Release

I grant and assign to the Department for the Blind and Vision Impaired, its agents, employees, designees, successors or assignees, all my rights, title and interest to photographic/recorded reproductions of me/my voice and consent that such photographs/recordings may be used in any manner for advertising and publicity. I further grant permission for the copyright of such photographs/recordings and consent that they may be reproduced either partially or in composite, or distorted in character or form, in conjunction with other photographs/recordings, names and reproductions made through any media. DBVI staff and individuals participating in DBVI sponsored programs may record lecture notes during sessions for content. I have read the above statement and am familiar with its contents.
** 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 submitting, double check phone numbers and email addresses. If not entered correctly, you will not receive an email with next steps.
Once you submit this application, you will see a blue screen which indicates the application was completed.