Short-Term Programs Referral Form

TSBVI SHORT-TERM PROGRAMS

Request for Referral

to a Short-Term Program Class

Thank you for your interest in sending your student to a TSBVI Short-Term Program (STP) class. Please submit the following information and you will soon be contacted to complete the application process:

Referrals must be made by a member of the local school district. This is usually the student’s Teacher of the Visually Impaired (TVI). Parents cannot refer to these classes except through their local district.

* - Indicates required field

STUDENT INFORMATION
*Student's Name:
*Student's Date of Birth:
*Current Grade:
*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:
*Best way and times to reach you:

*CHECK ALL CLASSES DESIRED

FALL SEMESTER
Elementary Access to Academic Skills #1 (grades 1-5), September 14–19
Junior Access to Academic Skills #1 (grades 6-8), October 5–10
High School Access to Academic Skills #1 (grades 9-12), October 19–24
“Traveling with Low Vision” Weekend (grades 9-12), Oct. 30 – Nov. 2
Math Tools and Concepts (taking algebra or more advanced class), November 3–7
Junior Access to Academic Skills #2 (grades 6-8), Nov 30–Dec. 5
Elementary School Independence Weekend #1 (ages 6-8), December 11 – 14

SPRING SEMESTER
High School Access to Academic Skills #2 (grades 9-12), January 11–16
Middle School Independence Weekend (grades 6-8) , Jan. 22–25
Elementary Access to Academic Skills #2 (grades 1-5), February 1–6
Elementary School Independence Weekend #2 (ages 9-11) , February 19–22
High School Access to Academic Skills #3 (grades 9-12), March 8–13
Low Vision Weekend (secondary), March 26–29
High School Independence Weekend #1: Prom (grades 10-12), April 2–5
Capitol Experience: The Legislative Process Up Close (grades 8-12), April 17–21
Junior Access to Academic Skills #3 (grades 6-8), April 26–May 1
High School Independence Weekend #2: Camping (grades 9-11), May 7–10

HAS THE STUDENT ATTENDED TSBVI IN THE LAST TWO YEARS? ***

Yes
No

IF YOUR ANSWER WAS NO, PLEASE FILL OUT THE FOLLOWING:

ACADEMIC LEVEL OF FUNCTION

MATHEMATICS:
What is this student's Math grade level?
Which Math TAKS did the student take?
Did the student pass?	Yes No

READING:
What is this student's Reading grade level?
Which Reading TAKS did the student take?
Did the student pass?	Yes No

How many hours of adult support does student receive in a typical week?:

What type of support does the student receive?:

How much time does student spend in settings other than the regular classroom?:

Please describe the other settings:

Any additional information you would like to provide?