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Virginia Department for the Blind and Vision Impaired Universal Application
To participate in these opportunities, students must be receiving Vocational Rehabilitation services or determined potentially eligible so that funding can be reserved for the selected activities.
Please contact your Education Coordinator, Vocational Rehabilitation Counselor, or call (800) 622-2155 to be connected to a Vocational Rehabilitation Counselor in your area.
If you have additional questions and want information regarding these services, please contact:
Felicia Williams, Pre-employment Transition Specialist, (804) 371-3164 or
Tish Harris, Pre-ETS and Career Pathways Coordinator, (540) 294-1215
Visit our website DBVI Students and Transition for updates and more information.
If you have questions about the Learning Independence, Feeling Empowered (LIFE) program, please contact:
Amy Phelps, Assistant Director for Instruction at the Virginia Rehabilitation Center for the Blind and Vision Impaired (VRCBVI), at (804) 371-3052 or visit the VRCBVI LIFE website
This application includes the following:
• Universal Application
• Waiver and Liability Form
• Student Contract
• Student Learning Contract (if you are applying for LIFE)
• Photographic Recording Release
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Applying for the Learning Independence, Feeling Empowered (LIFE) program? Complete this DBVI 2025 Universal Application and select the LIFE program below. Once you submit this DBVI Universal Application, you will receive a confirmation email with additional information needed to complete the LIFE application.
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Required fields will be marked with **.
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Select the programs you are interested in attending by checking the box below the program.
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Section 1:
Let's Get to Know You!
Student Information
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Describe any previous work and/or volunteer experience:
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Please provide details regarding the requested accommodations:
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** Describe any adjustment to blindness issues (ex: Student is newly blind or experiences challenges with activities of daily living):
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Section 2: Student Medical InformationStudents health and safety are of utmost importance to us. We require medical information to be considered for Residential Programs.
(2025 Residential Programs- LIFE Program, Blind Design, Spring Into Self Determination,
Cyber Space,
Careers in Action, and Launching Point)
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** Cause of blindness/vision loss, if unknown, enter unknown:
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Please provide any additional information regarding the above listed diagnoses and describe other conditions not listed above:
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** Does the student have diabetes?
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** Does the student have any medically-prescribed dietary needs such as renal diet, celiac diet?
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Activities of Daily Living - Does the student receive assistance at home with eating, dressing, bathing, using the bathroom, bowel care, or bladder care?
If yes, briefly describe activity restrictions and assistance provided.
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** Does the student have any psychological or emotional differences that may affect their ability to self-care/self-regulate?
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** Is the student able to actively participate/learn in group settings?
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** Does the student have any physical limitations or activity restrictions?
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If yes, please describe:
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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.
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Does student's allergy require an epi pen? If yes, student will need to bring epi pen and be able to self-administer.
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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):
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DBVI/VRCBVI uses an empowerment model of training and does not have any medical staff. Additionally, the focus of our programs is to promote independence. Therefore, DBVI/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 above listed programs:
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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 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
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Section 3: Parent / Guardian Information
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Please provide details regarding the requested parent accommodations:
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If you are student’s legal guardian, do you have a copy of the court documents demonstrating that?
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If the parents have joint custody, please fax the court custodial order to DBVI Attention: Felicia Williams at (804) 371-3164.
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.
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Emergency Contact Information
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** RELEASE, WAIVER OF LIABILITY, ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
In consideration of participation in the Virginia Department for the Blind and Vision Impaired
(DBVI)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 DBVI, 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 Releases, 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. This form shall be in force and effect from January 2025 through December 2025.
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** Student Learning Contract
Our primary goal is to offer an exciting and unique learning experience, while providing a safe and productive environment. We ask that parents and students review this list together.
Our expectations:
1. If the student is attending in person, they will only leave the dorm with an adult staff or mentor after notifying academy coordinator or dorm supervisor. (You will be notified of the appropriate staff to contact for the program you are attending.)
2. If attending virtually, respectful and appropriate communication is required.
3. Let an instructor or staff know about any concerns.
4. Treat all students and staff with courtesy and respect.
5. Not use cell phones during instructional or meeting times unless instructors have indicated cell phone use is acceptable during that portion.
6. Not bring on campus or use tobacco products or illegal substances such as drugs or alcohol.
7. Not engage in any behaviors that create unsafe or uncomfortable environments for others.
8. Actively participate in all aspects of the program
9. Follow any mask and safety protocols that may be in place at the time.
10. DBVI programs allow students to connect with their peers. We encourage networking. However, we ask students not to share their peers contact information without their permission.
**Note: If you are applying for the LIFE program, you will receive a separate Student Learning Agreement when you receive your next steps email from Brooke Rogers.
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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.
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** 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.
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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.
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