TSBVI SHORT-TERM PROGRAMS

* Indicates required field

STUDENT INFORMATION
*Student's Name:
*Student's Date of Birth:
*Current Grade (as of Fall 2009):
*Student's School District:
*School District City:

TEACHER OF THE VISUALLY IMPAIRED (TVI) INFORMATION
*TVI's Name:
*Best Phone to Reach You:
Alternate Phone Number:
*FAX:
*Your Email Address:

STUDENT'S PRIMARY GUARDIAN CONTACT INFORMATION
*Guardian's Name:
*Guardian's Relationship to Student :
*Best Phone To Reach Guardian:
*Street Address:
*City, State, Zip :
*Guardian's Email Address: (If none, type "N/A")

FALL SEMESTER - CHECK ALL CLASSES DESIRED
	Elementary Access to Academic Skills #1 (grades 1-5)	September 13 - 18
	Low Vision Tools & Strategies: Secondary	September 24 - 27
	Junior Access to Academic Skills #1 (grades 6-8)	October 4 - 9
	Chemistry Tools and Concepts (high school)	October 16 - 19
	High School Access to Academic Skills #1 (grades 9-12)	October 25 - 30
	Math Tools and Concepts (taking algebra or more advanced math class)	November 1 - 6
	City Travel: For COMS and Their Students	November 11 - 15
	High School Independence Weekend #1: Camping (grades 9 - 12)	December 3 - 6
	Elementary School Independence Weekend #1 (ages 9 - 11)	December 10 - 13

SPRING SEMESTER - CHECK ALL CLASSES DESIRED
	High School Access to Academic Skills #2 (grades 9-12)	January 10 - 15
	Looking Good (self care, independence, sexuality, socializing, and manners)	January 21 - 24
	Elementary Access to Academic Skills #2 (grades 1-5)	January 31 - February 5
	Junior Access to Academic Skills #2 (grades 6-8)	February 21 - 26
	"Traveling with Low Vision" Weekend (grades 9-12)	March 25 - 28
	Low Vision Tools & Strategies: Elementary	April 8 - 11
	High School Independence Weekend #2: Prom (grades 10-12)	April 15 - 18
	Elementary School Independence Weekend #2 (ages 6-8)	May 6 - 9
	Junior Independence Weekend (grades 6-8)	May 13 - 16

If you have selected a 5-day Access to Academic Skills class, what general skill set do you want your student to work on while at TSBVI? One of our teachers will call before the class begins to work with you on selecting specific goals for the class, so if you are uncertain at this time, that is fine. Just share your general thoughts:

 

VISION

*1. What is the student's primary learning medium? *Please Select* Auditory/Verbal Braille Large Print Regular Print Sign Language Tactile Symbols Other

*2. If student reads print, what size font can the student read with magnification?
      (If student does not read print, please type "Does Not Read")

*3. Visual Acuities -
        RIGHT:
        LEFT:  

*4. Any other visual limitations (field restrictions, nystagmus, etc.):
      (If None, please type "N/A")

 

ACADEMIC LEVEL OF FUNCTION

MATHEMATICS
*What is this student's tested MATH grade level?
*Which Math TAKS did the student take?	*Please Select* TAKS TAKS - M TAKS - ALT TAKS - ACCOMM Not Applicable
*Did the student pass?	Yes     No

READING
*What is this student's tested READING grade level?
*Which Reading TAKS did the student take?	*Please Select* TAKS TAKS - M TAKS - ALT TAKS - ACCOMM Not Applicable
*Did the student pass?	Yes     No

 

OUT OF CLASS SUPPORT
How many hours per week does the student spend in settings other than the regular classroom?

Please describe these other settings:

IN CLASS SUPPORT
When in the regular classroom, how many hours per week of adult support does the student receive from someone other than the classroom teacher?

What type of support does the student receive?

OTHER INFORMATION

*Describe any physical or medical issues affecting participation in school or mobility:
(If None, please type "N/A")

Anything else you would like to tell us about your student?

Note: Please keep a copy of this referral, because you may be asked to re-enter some information when filling out an official application. This limited referral is only intended to help us evaluate the appropriateness and general direction of services at the referral stage. After receiving this referral, you will receive a phone call or email regarding official acceptance.

Before you submit this proposal, please be certain that the student, family and school district are committed to the requested classes. Help families understand that all our classes are highly competitive and intensive, including the weekends. They are not a camp! Our referral rate has exploded to the point that we can no longer deal with the additional workload caused by large numbers of dropouts and last minute substitutions. Of course we understand that illness would prevent attendance, but we hope that would be the only reason for dropping out close to the time class begins. We greatly appreciate your help with this!