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

Date

STUDENT INFORMATION

Student Name*

First NameLast Name

Gender*

MaleFemale

Date of Birth*

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

Date

Who did the evaluation? Findings*

Hearing Evaluation Summary

Date of Evaluation

Date

Who did the evaluation? Findings*

Does the student have a cochlear implant?*

YesNo

IEP or IFSP Summary

Date *

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

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PARENT'S SIGNATURE

SCHOOL CONTACT SIGNATURE (who submitted this form)*