Girls and Boys Weekend March 29-31, 2019
This is the registration for the Spring 2019 Girls and Boys Weekend event at Kansas State School for the Blind. Participants must be age 14 and older to attend. Participants must be independent in all self-care. Please contact Aundrayah Shermer, ashermer@kssdb.org, with any questions. Registration is limited to 20 participants!
Email address *
Date *
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Name of Participant *
Your answer
Birthdate *
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Participant Grade (current) *
Your answer
School District Name *
Your answer
Participant Vision Diagnosis *
Your answer
Participant Visual Acuities (if known)
Your answer
Participant Teacher of Students with a Visual Impairment (TSVI) *
Your answer
Participant Parent/Guardian Name *
Your answer
Participant Home Address (include city and zip code) *
Your answer
Phone (including area code) *
Your answer
Parent E-mail *
Your answer
Emergency Contact 1 (Name and phone #) *
Your answer
Emergency Contact 2 (Name and phone #)
Your answer
Family Doctor *
Your answer
Family Doctor Phone # *
Your answer
Allergies (drug,food, etc) *
Your answer
Medication/Amount and Time Given *
Your answer
Reason for medications *
Your answer
Name of Health Insurance Company *
Your answer
Name of Policy Holder *
Your answer
Group # *
Your answer
Individual # *
Your answer
Medical Card (SRS) # (If Applicable)
Your answer
Parent Signature/ Type name here for signature *
Your answer
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