KS Deaf-Blind Project Certification Application

DeafBlind Project Certification Application
REQUESTED INFORMATION CHECKLIST

Application form (please complete all sections)Parent email(s)Parent consentCurrent vision report by an ophthalmologist, optometrist or a doctorCurrent audiologist reportCurrent IEP/IFSPOptional: Functional Vision & hearing evaluations may be submitted for additional information. You may access the forms on our website: https://www.kansasdeafblind.org/
KANSAS 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
USD #/School District or Program *
School*
School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County the student lives in*
Parent #1*

First NameLast 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*
Please enter a valid phone number.
Parent #2

First NameLast Name
Parent #2 Address (leave blank if it's the same address as parent #1)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent #2 Email
example@example.com
Parent #2 Phone Number
Please enter a valid phone number.
SCHOOL CONTACT INFORMATION
School Contact Person*

First NameLast Name
School Contact's Email*
example@example.com
School Contacts Phone Number (with area code)*
Please enter a valid phone number.
VISION EVALUATION
Does the student have CVI?*

YesNoUnsure
Date of Evaluation*

MonthDayYear
Date
Please upload a current vision report by an ophthalmologist, optometrist or a doctor

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Brief summary of the child's vision
HEARING EVALUATION
Does the student have a cochlear implant?*

YesNo
Date of Evaluation*

MonthDayYear
Date
Please upload a current audiologist report

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Brief summary of the child's hearing
IEP or IFSP
Date of current IEP or IFSP*

MonthDayYear
Date
Please upload a current IEP or IFSP for the student

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PARENTAL CONSENT

Click here to access a printable parental consent form

Click here to access the electronic parental consent form.

**If parents submit the electronic consent, it will be automatically sent to the KSDBP, so no need to include or send a copy.
Please upload the Parental Consent Form if it was completed on paper (no need to upload it if it was completed electronically)

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Upload any additional documents that may be helpful in determining whether or not the student qualifies for a certification.

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Should be Empty:

DeafBlind Project Certification Application