2019 VRCBVI LIFE APPLICATION

VRCBVI Application - 2019 LIFE Program (“Learning Independence, Feeling Empowered!”) Dear LIFE 2019 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 2019 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 able to actively participate in all five weeks of the program (unless returning to school) • Be between 14 and 18 years old and be returning to a high school academic program in the fall of 2019 (14 years old on or before July 26 and must not turn 19 years old before August 9) • Be blind or vision impaired and interested in acquiring blindness skills • 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) 1) VRCBVI 2019 LIFE application form (see below) 2) DBVI health checklist/general medical form completed by a medical professional and dated no more than one year prior to the LIFE application deadline date of April 12, 2019. If a student attended a summer program at VRCBVI in 2018, the health form submitted for that program is acceptable, provided the parent(s) submit a statement that the student’s 2019 health information has not changed and the form is still accurate 3) DBVI eye report form completed by a medical professional and dated no more than one year prior to the LIFE application deadline date of April 12, 2019. If a student attended a summer program at VRCBVI in 2018, the eye report form submitted for that program is acceptable, provided the parent(s) submit a statement that the student’s 2019 eye report information has not changed and the form is still accurate 4) 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 10, 2019 of their acceptance status. If the applicant is accepted into the 2019 LIFE program, we will send you liability waivers and activity forms that you will be required to sign and return to VRCBVI prior to the program start date, July 7, 2019 in order for the applicant to participate in the program. If, after the applicant has been accepted into the 2019 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 12, 2019. NO APPLICATIONS FOR THE 2019 LIFE PROGRAM WILL BE ACCEPTED AFTER THIS DATE. Dates of Program: The five week program begins Sunday, July 7, 2019, and will end on Friday, August 9, 2019, 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 2019 Student Application

Student Information

Student’s Name: Student’s Name:

Grade (Fall 2019): 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?

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 #1):

Parent/Legal Guardian Phone (Cell #2)Parent/Legal Guardian Phone (Cell #2)

Parent/Legal Guardian Phone (Home):

Parent/Legal Guardian Phone (Work):

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

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

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

Student Medical Information

Does the student have other disabilities in addition to blindness?

Yes No

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

Does the student have any psychological or emotional disabilities?Describe any medical, psychological, emotional, or physical limitations:

Yes No

If yes, briefly describe the psychological and/ or emotional issues:

Specify any special socialization needs, if none, type N/A:Specify any special socialization needs:

Does the student have any physical limitations or activity restrictions?

Yes No

If yes, briefly describe physical limitations or activity restrictions:

Does the student have diabetes?

Yes No

If yes, please check all that apply about the student's diabetes management plan:

student independently checks blood sugar levels as ordered by doctor student independently takes diabetes pills as ordered by doctor student independently administers insulin injections as ordered by doctor student has a plan for handling low blood sugar levels request in-home diabetes education from the VRCBVI Diabetes Educator prior to LIFE

Does the student have any other chronic medical condition(s) that require a management plan, such as asthma, migraine disorder, seizure disorder, anxiety, etc.?

Yes No

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 LIFE, etc.)

Name and phone number of student's primary care physician:Primary Care Physician

Name and phone number of student's ophthalmologist:Ophthalmologist

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

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 List

Medication Management Plan

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 all that apply):

student does not take any prescription or over-the-counter medications student fills and uses a pill box independently parent to fill pill box, but student to independently take medications student independently takes medications out of containers when needed student needs reminders, but has set-up a reminder on phone or note-system student needs reminders, but has set-up a reminder system with parent student needs supervision, but has developed a plan with parent, such as using face time, Skype or webcam no administration plan in place; request in-home education from the DBVI Health Educator prior to LIFE

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 LIFE 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.

Yes, I understand and agree I request a phone consultation with the VRCBVI Diabetes/ Health Educator to help establish a plan to obtain refills

Does the student have any medically-prescribed dietary needs, such as renal diet, celiac diet? If so, list here:

Are special accommodations needed in the dormitory?

Adapted bathroom Deafblind accommodations 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)?

Yes No

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

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

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?

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?

Emergency Contact Information

Emergency contact name, phone number and relationship to student:Emergency contact name, phone number and relationship to student:

Emergency contact address: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 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?

Yes No N/A

If yes, please fax a copy of the legal guardianship court order to VRCBVI 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 LIFE program must be signed by both parents.

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

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

Signatures

Applicant’s Signature:Applicant’s Signature:

Custodial Parent/Legal Guardian #1 Signature:

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

Student Learning Contract VRCBVI LIFE 2019 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: