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.
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