2020 VRCBVI and University of Richmond STEPS to Success Application

Student Information

Student’s Name: Student’s Name:

Grade (Fall 2020): Grade Fall 2021

rising high school junior rising high school senior high school graduate (Spring 2020)

Date of birth (mm/dd/yyyy): Date of birth (mm/dd/yyyy):

Mailing Address: Mailing Address:

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

Studentss cell number. Enter NA if students does not have a cell phone: Student’s cell number. Enter NA if students does not have a cell phone:

Student’s email address. (Student must have working email address for STEPS to Success program):Student’s email address. (Student must have working email address for Steps to Success program):

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:

Parent / Guardian Information

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

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

Parent/Legal Guardian name and phone number (#1):Parent/Legal Guardian name and phone number (#1):

Parent/Legal Guardian name and phone number (#2):Parent/Legal Guardian name and phone number (#2):

Parent/Legal Guardian name and phone (Home):

Parent/Legal Guardian name and phone (Work):Parent/Legal Guardian name and phone (Work):

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):

Parent/Legal Guardian name and email address:Parent /Guardian name and email address:

Student Medical Information

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

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:

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:Does the student have other disabilities in addition to blindness?

Does the student have any physical limitations or activity restrictions?Does the student have any physical limitations or activity restrictions?

Yes No

If yes, briefly describe physical limitations or activity restrictions:If yes, briefly describe physical limitations or activity restrictions:

Does the student have diabetes?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 the STEPS to Success program

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

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):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 Management Plan

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 STEPS to Success 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 STEPS to Success program

If needed, please list any additional, pertinent information about student's medication administration here: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 STEPS to Success 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? Does the student have any medically-prescribed dietary needs, such as renal diet, celiac diet?

Yes No

If yes, please describe any dietary needs below: If yes, please describe any dietary needs below:

Are special accommodations needed in the dormitory?

Wheelchair accessible bathroom Deafblind accommodations NA

If you selected a special accommodation above, please describe what accommodations are needed:If you selected a special accommodations above, please describe what accommodations are needed:

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 rehabilitation counselor’s or education coordinator’s name here:

What are the student’s goals for attending the STEPS to Success program?What are the student’s goals for attending the Steps to Success program?

Is there anything else the student wants the VRCBVI and the University of Richmond staff to know?Is there anything else the student wants the VRCBVI and the University of Richmond staff to know?

Emergency Contact Information

Emergency contact name, phone number and relationship to student (not provided above):Emergency contact name, phone number and relationship to student (not provided above):

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

If yes, please fax a copy of the legal guardianship court order to VRCBVI, Attention: Brooke Rogers at (804) 371-3092. If no, please explain:If yes, please fax a copy of the legal guardianship court order to VRCBVI, Attention: Brooke Rogers at (804) 371-3092.

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 STEPS to Success 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

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: