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2019-20 Transition Program Application
This application must be completed as a part of the KSSB admissions to Transition program. Please contact Lori Smith if you have any questions. Lori's email is lsmith@kssdb.org.
Email address *
Student Name
Provide full name
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Current grade *
Student Home Address *
List primary residence
Your answer
Parent Name and Phone *
Your answer
Parent Email(s) *
Your answer
Student Cell Phone & Email *
Your answer
USD # and Name of High School *
Your answer
TVI Name *
Your answer
TVI Phone and Email *
Your answer
O&M Name
Your answer
O&M Phone and Email
Your answer
Eye Doctor *
Name
Your answer
Date of Last Eye Exam *
MM
/
DD
/
YYYY
Date of Last Low Vision Eval
MM
/
DD
/
YYYY
Student's Eye Condition(s) *
Your answer
Visual Acuity and Field
If available
Your answer
List Low Vision Aids
List those student is currently using
Your answer
Does the student have an open case with Vocational Rehabilitation *
Voc Rehab Counselor
Name
Your answer
Transition Skills requested *
May select more than one
Required
Has student taken ACT or SAT? *
If yes, provide scores
Overall
Your answer
Note Taker currently used
Accessibility Software/Devices Currently Used
Typing Rate
Student Cell Phone Used
Current Braille Format
Reading Grade Level
Current print medium
Print grade level
What other SPED services does the student receive? *
Required
List work experience student has participated in
Your answer
Student's Vocational Interests *
Your answer
List behaviors which may interfere with student's potential or progress *
Your answer
Pertinent Medical or other information
Your answer
Typing your name here serves as your signature, but does not guarantee acceptance into the Transition program. *
Your answer
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