Personal Information s4

2017 SKILLS- Vancouver APPLICATION

Monday, July 24 through Friday, July 28, 2017

PERSONAL INFORMATION Student Name: Address: City/Zip: E Mail Address: Date of Birth: Gender: ☐Female ☐ Male Phone Number: ( )

Social Security Number ______- ____ - ______☐ not applicable *Note: if emailing SKILLS application, do NOT electronically transmit SSN. Instead, call Marcie Ebarb’s confidential voice mail at (360) 947-3286 and leave full SSN. Student has ☐ IEP ☐ 504 Plan Race: ______Ethnicity: ______

Parent or Guardian - #1 Name: ______Address :( Street) ______(City)______(State) ______(Zip) ______(If different from student address) Phone: ( ) ______Email: ______

Parent or Guardian - #2 Name: ______

Address :( Street) ______(City)______(State)______(Zip) ______

1 (If different from student address) Phone: ( ) ______Email ______

Name of school: Vision Teacher Name: Phone number: ( ) ______Email: ______Orientation and Mobility Specialist Name: ______Phone number: ( ) ______Email: ______

EMERGENCY CONTACT PHONE NUMBERS

Contact #1 Name: ______

Home # :( ) ______Cell # :( ) ______

Work #: ( ) ______

Contact #2 Name: ______

Home # :( ) ______Cell # :( ) ______

Work #: ( ) ______

MEDICAL/SPECIAL NEEDS INFORMATION To insure the safety and wellbeing of all students, please provide full disclosure to the following questions. Lack of disclosure or incomplete information regarding medical, behavioral or emotional issues that could potentially interfere with a student’s participation in program objectives, or that could affect the safety and wellbeing of camp participants and staff, will be grounds for termination from Camp.

Please answer the following questions so we are able to better plan for a safe appropriate and fun experience for all.

Please define the student’s visual impairment and diagnosis ______☐ Legally Blind ☐ Totally Blind ☐ Visually Impaired

2 Other Disabilities (if any): ______

______Please describe any medical, emotional and/or psychological considerations/conditions and list current medications (if any):

______

Does the student eat independently? ☐ Yes ☐ No Comments: (please describe any dietary restrictions /food allergies, etc.) ______Does the student use any mobility devices/accommodations (other than a long white cane) (examples: wheelchair, walker, interpreter, etc.) ☐ No ☐ Yes, the student uses______Does the student travel independently in familiar environments? ☐ Yes ☐ No Comments: ______Does the student toilet independently? ☐Yes ☐ No Comments: ______Does the student read at or near grade level? ☐ Yes ☐ No What is the student’s reading and writing medium? ☐ Braille ☐ Large Print ☐ Regular Print ☐ Nonreader Please return this application No later than May 31, 2017 To: Marcie Ebarb Washington State School for the Blind I. 2214 E 13th Street Vancouver WA 98661

3 or [email protected]