Deaf-Blind Project Certification Application

REQUESTED INFORMATION CHECKLIST:

Application form. Please complete all sections. Parent email(s) Current vision report by an ophthalmologist, optometrist or a doctor Current audiologist report Current IEP or IFSP Optional: Functional Vision & hearing evaluations may be submitted for additional information. You may access the forms on our website: https://www.kansasdeafblind.org/
If you have any questions,

Email: maltuna@kssdb.org

Call: 913-645-5645
DEAF-BLIND PROJECT CERTIFICATION APPLICATION
This application is *

Initial Certification Re-certification
Date of Application

Month Day Year
Date
STUDENT INFORMATION
Student Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
School *
School address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
USD#/school district or Tiny-K Program *
Parent #1 *

First Last Name
Parent #1 Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent #1 Email *
example@example.com
Parent #1 Phone Number *

Area Code Phone Number
Parent #2

First Last Name
Parent #2 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent #2 Email
example@example.com
Parent #2 Phone Number

Area Code Phone Number
SCHOOL CONTACT INFORMATION
School Contact Person *

First Name Last Name
School Contact's Email *
example@example.com
School Contact's address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
School Contact's Phone Number *

Area Code Phone Number
Vision Evaluation Summary
Date of Evaluation

Month Day Year
Date
Who did the evaluation? Findings *
Hearing Evaluation Summary
Date of Evaluation

Month Day Year
Date
Who did the evaluation? Findings *
Does the student have a cochlear implant? *

Yes No
IEP or IFSP Summary
Date *

Month Day Year
Date
Findings *
Parental Consent
I give consent for my child's school/district to release information about my child to the Kansas Deaf-Blind Project. I also agree to allow consultants from the Kansas Deaf-Blind Project to observe my child in person or online and to provide technical assistance to the school team if requested by the school team. *

Yes No
I give consent for the KS Deaf-Blind Project to submit my child's name and information to the Helen Keller National Center for additional services. *

Yes No
I give consent for the KS Deaf-Blind Project to release information about my child to the KS State School for the Blind and KS School for the Deaf. *

Yes No
FOR STUDENT WITH CHARGE SYNDROME ONLY: I give my consent for the KS Deaf-Blind Project to submit my child's name and information to the KS Parent Liaison of the CHARGE Syndrome Foundation *

Yes No This student does not have a CHARGE Syndrome
If it is not possible to obtain a parent signature, please have the parent email you stating they are giving consent to share their child's information to the organizations stated above. Please attach the emailed consent to this application (or you may forward the emailed consent to maltuna@kssdb.org. Thank you.
Upload supporting documents here OR scan and email separately to maltuna@kssdb.org OR mail it to: Marites Altuna, Kansas Deaf-Blind Project 1100 State Ave., Kansas City, KS 66102

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PARENT'S SIGNATURE

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SCHOOL CONTACT SIGNATURE (who submitted this form) *

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