2018 Summer Program Participant Application
Kansas Summer Expanded Education (K.S.E.E.)
Vocational Program
KS-PREP Program
K.S.E.E. - HAYS Program

SEE BROCHURE FOR PROGRAM DETAILS (including age/grade requirements)

The application is not considered complete until parent signature forms, and a copy of the IEP are submitted.

Full applications are accepted by paper AND on-line for summer 2018. Scan all required information as an e-mail attachment to:

Renee Wilson reneewilson@kssdb.org

For questions on the application process contact:
Aundrayah Shermer, ESY Coordinator ashermer@kssdb.org , 913- 305-3016

Kansas State School for the Blind
Date *
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PLEASE INDICATE WHICH PROGRAM YOU ARE APPLYING TO: *
Please list anticipated absences (date and reason) during the summer 2018 program:
Your answer
Name of Participant: *
Your answer
Participant Date of Birth: *
MM
/
DD
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YYYY
Participant Full Address (including zip code) *
Your answer
Parent or Guardian Full Name: *
Your answer
Parent or Guardian Home Address: *
Parent or Guardian Phone number (include area code) *
Your answer
Parent or Guardian E-mail (Please indicate email checked often) *
Your answer
Participant School District: *
Your answer
Participant grade for 2017-18 academic year: *
Your answer
Participant's Teacher of Students with a Visual Impairment and/or Certified Orientation and Mobility Specialist (TVI or COMS): *
Your answer
Participant's Vision Diagnosis: *
Your answer
Participant's Visual Acuities (Right Eye, Left Eye, Both Eyes if known):
Your answer
Participant's Reading Medium (select all that apply) *
Required
Does Participant wear glasses?: *
Does Participant Use a White Cane?: *
Does Participant Use Hearing Aids (or have a Cochlear Implant)?:
The Expanded Core Curriculum (ECC) is the focus during our 2018 summer programs. Please share information on Participant with the following ECC domains and how we can assist your participant skills in these areas (see brochure for more information): Recreation/Leisure, Activities of Daily Living, Assistive Technology, Orientation and Mobility, Social Skills/Self-Determination, Transition, and Career Exploration: *
Your answer
Participant technology used (Please note - KSSB is not responsible for lost of stolen electronics): If None, please list NONE: *
Your answer
Will Participant Be Residing in the KSSB Dorm?: *
Emergency Contact / Medical Information
Official parent/guardian signature on Consent and Release forms will be required before application is considered complete.
Emergency Contact 1 Full Name(s) and Phone Number(s): *
Your answer
Emergency Contact 2 Full Name(s) and Phone Number(s): *
Your answer
Participant Medical Conditions (Ex: Seizures, Diabetes, Austism, Behavior, Sleep, etc). If No medical conditions, please list NONE: *
Your answer
Participant Allergies (Ex: Medicines, Foods, Enviornmental, Seasonal) If No Allergies, please list NONE: *
Your answer
Additional Information to share with Participant's Summer Education team (If None, please list NONE): *
Your answer
Participant's special diet information (If None, please list NONE): *
Your answer
Participant family doctor (Include name and phone number): *
Your answer
Has Participant had a complete physical in the past 12 months?: *
Does Participant take medications?: *
If answered YES above, please provide list of medications participant takes (Please include name of medicine, dosage, time given, and any comments regarding each medicine): If None, please list NONE: *
Your answer
Some medications considered "over the counter" are available at the KSSB Health Center during the 2018 Summer Programs. These medications are only given if age appropriate (12 and older). Is Participant allowed to have common "over the counter medications": *
Name of Health Insurance Company *
Your answer
Name of Policy Holder *
Your answer
Insurance Policy Group # *
Your answer
Insurance Policy Individual # *
Your answer
Medical Card (SRS) # If None, please list NONE:
Your answer
NOTE - Application is not considered complete until KSSB receives consent/release forms (with parent/guardian signature), Residential Services Information form (if staying in the dorm), copy of IEP (including behavior plan if applicable), official medication Information (if applicable). Type name here for signature: *
Your answer
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