Parent's Name(s):

Address:

City:      State:      Zip:

Home Phone:       Work Phone:

Email:

Name of child's vision teacher:

Name of child's vocational rehabilitation counselor (if any):

INFORMATION ABOUT YOUR CHILD

M/F:      Age:       Date of Birth:

Grade in school (fall 2008):

Cause of blindness:

Visual acuity: Right eye: Left eye: Field:

Has your child ever been away from home (y/n):

BLINDNESS SKILLS TRAINING

Does your child read braille (y/n)?

If yes, uncontracted or contracted?

Words per minute reading:

What does your child use to write braille? (slate & stylus, brailler, Braille Note, PACmate, etc.)

Does your child use a cane (y/n)?

Has your child had any computer training?

If yes, using which program for accessibility (i.e., JAWS, Window-Eyes, ZoomText, etc.)?

Has your child ever worked with any hand tools (i.e., hammer, click rule, etc.)? (y/n)

If yes, which ones?

Hobbies/interests:

Does your child know how to swim?(y/n)

Please provide additional detail:

Does your child require any floatation devices?(y/n)

Please provide additional detail:

What are your child's favorite foods (including breakfast)?

What are your child's least favorite foods?

MEDICAL INFORMATION

Does your child take any medications on a regular basis? (y/n) If yes, please fill in the fields below:

Reason for medication:

Does your child administer the medication independently?

Additional comments:

Reason for medication:

Does your child administer the medication independently?

Additional comments:

Reason for medication:

Does your child administer the medication independently?

Additional comments:

If there are additional medications, please attach a separate sheet.

Does your child have any allergies? If yes, please explain:

Does your child have any dietary restrictions? If yes, please explain:

Please list any other questions or concerns that you may have, or information that you would like us to have:

Up to 10 children will be accepted into the program. Unfortunately we are unable to accept all the individuals applying to the Buddy Program as we receive more applications than space available.

While the Buddy Program is supported primarily through grants, this does not cover the entire cost for operating the program. If your child is accepted into the Buddy Program the individual fee for this year will be $125.00. This fee can be paid through your state rehabilitation agency, your child’s school by inclusion in the IEP, individually, or any other source(s). If you would like assistance in working with any of these agencies please let us know. Some scholarships for fee waivers may be available. Please contact us for further information.

Signature of Parent or Legal Guardian: __________________________ Date: __________

TAKE A TOUR** We invite you to take a tour of our facilities and learn more about our program. Please call (612) 872-0100, or our toll-free number 1-800-597-9558, to arrange a visit.