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 doctorCurrent audiologist reportCurrent IEP or IFSPOptional: 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: kkirchhoff@kssdb.org

Call: 913-375-5239
DEAF-BLIND PROJECT CERTIFICATION APPLICATION
This application is*

Initial CertificationRe-certification
Date of Application

MonthDayYear
Date
STUDENT INFORMATION
Student Name*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
School*
School address*

Street Address

Street Address Line 2

CityState / Province

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

FirstLast Name
Parent #1 Address*

Street Address

Street Address Line 2

CityState / Province

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

Area CodePhone Number
Parent #2

FirstLast Name
Parent #2 Address

Street Address

Street Address Line 2

CityState / Province

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

Area CodePhone Number
SCHOOL CONTACT INFORMATION
School Contact Person*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Contact's Phone Number*

Area CodePhone Number
Vision Evaluation Summary
Date of Evaluation

MonthDayYear
Date
Who did the evaluation? Findings*
Hearing Evaluation Summary
Date of Evaluation

MonthDayYear
Date
Who did the evaluation? Findings*
Does the student have a cochlear implant?*

YesNo
IEP or IFSP Summary
Date *

MonthDayYear
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.*

YesNo
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.*

YesNo
I give consent for the KS Deaf-Blind Project to submit my child's name and information to Families Together for additional resources and services.*

YesNo
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.*

YesNo
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*

YesNoThis 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 kkirchhoff@kssdb.org

Thank you.
Upload supporting documents here OR scan and email separately to kkirchhoff@kssdb.org OR mail it to: Katie Kirchhoff, Kansas Deaf-Blind Project 1100 State Ave., Kansas City, KS 66102

Browse Files

Cancelof
PARENT'S SIGNATURE

Clear
SCHOOL CONTACT SIGNATURE (who submitted this form)*

Clear
Should be Empty: