2022 VRCBVI LIFE APPLICATION

VRCBVI 2022 LIFE “Learning Independence, Feeling Empowered!” Program Application Dear LIFE 2022 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 2022 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 2022 (14 years old on or before July 11, 2022 and must not turn 19 years old before August 12, 2022) • Be blind or vision impaired and interested in acquiring blindness skills • Be able to participate in group structured classes and activities • Be able to take care of personal care needs independently, including managing and self-administering medications • Have a valid government issued photo ID • Have an open or be willing to open a Vocational Rehabilitation case with DBVI Application Check List: All applications must include the following documents: (Only complete applications submitted by the deadline will be considered.) 1) VRCBVI LIFE 2022 Student Application form (see below) 2) DBVI Health Checklist/General Medical Examination completed by a medical professional and dated no more than one year prior to the LIFE application deadline date of May 8, 2022. If a student attended a summer program at VRCBVI in the past the health form submitted for that program is acceptable, provided the parent(s) submit a statement that the student’s 2022 health information has not changed and the form is still accurate. 3) DBVI Eye Exam Report completed by a medical professional and dated no more than one year prior to the LIFE application deadline date of May 8, 2022. If a student attended a summer program at VRCBVI in the past, the eye report form submitted for that program is acceptable, provided the parent(s) submit a statement that the student’s 2022 Eye Exam Report information has not changed and the form is still accurate. 4) Copy of the student’s current IEP Acceptance Status: After the application deadline, May 8, 2022, all complete applications will be reviewed. All applicants will be notified by May 25, 2022 of their acceptance status. **A maximum of 22 applicants will be accepted to the 2022 LIFE Program. If the applicant is accepted into the program, we will send you a VRCBVI LIFE Welcome Packet which includes liability waivers and activity forms that you will be required to complete, sign and return to VRCBVI. The return deadline for forms and waivers will be provided in the LIFE Welcome Packet. If, after the applicant has been accepted into the 2022 LIFE program, he/she decides to cancel participation, please contact Greg Chittum, Coordinator for Community Engagement at 804-371-3204 or greg.chittum@dbvi.virginia.gov so students who are on the waiting list can be scheduled. Important Information to Remember: Deadline for Application: May 8, 2022. NO APPLICATIONS FOR THE 2022 LIFE PROGRAM WILL BE ACCEPTED AFTER THIS DATE. Only complete applications will be considered. Dates of Program: The five week program begins Sunday, July 10, 2022 at 1:00, and will end on Friday, August 12, 2022, 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, evening activities, and Saturday confidence building activities. Work Experience: Students who are 16 to 18 years old will work part-time in a community-based setting during the last three weeks of the LIFE program. In some instances staff and/or parents will recommend that a 16 to 18 year old student continue to focus on blindness skills (Travel skills, Braille, Access Technology, and Cooking) during the last three weeks of the program. Students who are 14 to 15 years old will not participate in a work experience. However, they will participate in the full five weeks of blindness skills training. This will benefit those students who do not have the opportunity to receive continuous blindness skills training during the school year. Additional questions: For additional information about the 2022 LIFE Program, please contact Greg Chittum, Coordinator for Community Engagement, by phone (804-371-3204) or email greg.chittum@dbvi.virginia.gov or refer to the flyer on our website, VRCBVI LIFE. If you have questions about the application process, please contact Brooke Rogers, Assistant Director for Administration, at (804) 371-3338, or by email at Brooke.Rogers@dbvi.virginia.gov. **Subject to change due to COVID protocols. 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) 371-3204 Fax: (804) 371-3092 Facebook: VDBVI Website: VRCBVI

LIFE 2022 Student Application

Please indicate the name of the person completing this form and his/her relationship to the applying student. Name:

Relationship to applying student:

Student Information

Student’s First Name: First name

Student's Middle Initial:Middle initial

Student's Last Name:Last name

Grade ('22-'23 academic year): Grade fall 22

Date of birth: Date of birth

Will the student be able to attend all 5 weeks of the program?

Yes No

If you answered "no" above, please explain below:

Mailing Address (please include street, city, state and zip code): Mailing Address

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

Student’s cell number (if the student does not have a cell phone, please enter N/A): Student cell number

Student’s email address (this is the email address we will use to communicate with the student during the program if he/she is accepted - 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):Student email address

Cause of blindness:Cause of blindness

Visual acuity: Visual acuity

Field of vision: Field of vision

Describe any adjustment to blindness issues:Adjustment to blindness

Has the student ever attended a summer training program? If so, please list the program(s) and date(s) of attendance. Prior trainings

Parent / Guardian Information

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

Parent/Legal Guardian Address:Parent Guardian Address

Parent/Legal Guardian Phone Number (Cell #1):Parent Guardian Cell 1

The number listed above belongs to:

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

The number listed above belongs to:

Parent/Legal Guardian Phone (Home):Parent Guardian Home

The number listed above belongs to:Parent home name

Parent/Legal Guardian Phone (Work):Parent Guardian Work

The number listed above belongs to:Parent work name

Parent/Legal Guardian email address:Parent email

Best time of day to contact:Best time to contact

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

If you are student’s legal guardian, do you have a copy of the court documents demonstrating that? Legal guardian documentation

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:Fax legal documents or 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)Names of those with legal custody

I have sole legal custody of applicant (please provide name): Name of adult with sole custody

Emergency Contact Information

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

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):Student will return to this address if dismissed

Student Medical Information

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

Yes No

If yes, list other disabilities here: List other disabilities

Does the student have any psychological or emotional disabilities?Psychological emotional disabilities

Yes No

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

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

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

Yes No

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

Does the student have diabetes?Diabetes

Yes No

Diabetes plan

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.?Other chronic medical conditions

Yes No

If yes, please list the chronic medical diagnosis and the established management 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):List other medical plans

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.)Any other medical issues

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, enter N/A.List allergies

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 enter 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 VRCBVI Health Educator prior to LIFE

If needed, please list any additional, pertinent information about student's medication administration here:Additional medication info

Refills

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? Dietary needs

Yes No

Please describe any dietary needs below: Describe dietary needs

Special accommodations

Are special accommodations needed?

Dorm room with a wheelchair accessible bathroom Deafblind accommodations N/A

If you requested deafblind accommodations above, please list them here:Describe deafblind accommodations

Additional Student Information

Does the student have an open Vocational Rehabilitation (VR) case with the Virginia Department for the Blind and Vision Impaired (DBVI)? Open VR case

Yes No

If yes, please provide the rehabilitation counselor’s name here:DBVI counselor

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

What does the student enjoy doing in his/her free time?Do during free time

Students who are 16 to 18 years old will work part-time in a community-based setting during the last three weeks of the LIFE program. In some instances staff and/or parents will recommend that a 16 to 18 year old student continue to focus on blindness skills (Travel skills, Braille, Access Technology, and Cooking) during the last three weeks of the program. Students who are 14 to 15 years old will not participate in a work experience. However, they will participate in the full five weeks of blindness skills training. This will benefit those students who do not have the opportunity to receive continuous blindness skills training during the school year. If your student is between the ages of 16 and 18, please list jobs the he/she would be interested in doing. If your student is 14 or 15, please enter N/A:List jobs of interest

Does the student have any previous work experience?Prior work experience

Yes No

If yes, list employer(s) and types of jobs performed.List prior jobs and tasks

Is there anything else the student wants VRCBVI staff to know?Anything else

Signatures

By checking this box, I acknowledge that I understand that the student's application is considered incomplete until the following documents are submitted along with this form: o DBVI Health Checklist Form, o General Medical Examination Form, o DBVI Eye Exam Report, o student’s current IEP

I understand

Applicant’s Signature:Applicant Signature

Custodial Parent/Legal Guardian #1 Signature:Parent Guardian signature 1

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

Student Learning Contract To maximize learning, we have identified expectations to ensure a safe, productive summer. We ask that parents and students review the following. The expectations are as follows. Students and parents will agree to the following: 1. Never leave the facility without an adult. 2. Never leave VRCBVI campus without checking with staff. 3. Be responsible for telling the Center Case Manager (Kris Foley) or Administration about any problems. 4. Treat all students and staff with respect. 5. Only gather with other students in approved common areas. 6. Use your cane at all times. 7. Wear learning shades during classes and occasionally during evening and weekend activities. 8. Will not use cell phones during instructional times without instructor permission. 9. Will not possess or use illegal drugs, alcohol or marijuana. 10. Actively participate in all aspects of the program, including evening and weekend activities.

Please sign below to certify that you have read and understand the student expectations. Further, be aware that failure to follow these policies can result in expulsion from the program.

Student Signature:Student Learning Contract signature

Custodial Parent/Guardian Signature:Custodial Parent/Guardian Signature: