PROJECT STEP APPLICATION
Summer Transition and Employment Program JUNE 9 – 27, 2008


*NOTE -- An Email address must be provided in order to submit this form! If you do not have an email address then write, I do not have an email, in the
student email form field.

Location: St. Louis Society for the Blind and Visually Impaired
8770 Manchester Road
St. Louis, MO 63144
Phone: 314-968-9000
Fax: 314-968-9003

Application Deadline: May 1, 2008
Email, Print and mail or fax the completed application to above address or fax number.

Direct any questions to:
Kevin Hollinger, Director Project STEP kjhollinger@sbcglobal.net phone, 636-578-0124

Beginning of STEP form

STUDENT INFORMATION:
Student Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Age in 2008:
Home Phone:
Student Email: (REQUIRED) If you don't have one write: I do not have an email
Parent or Guardian Name:
Parent or Guardian Email:
School District:
Grade:
Vision Teacher:
O&M Specialist:
Student Diagnosed Visual Impairment:
Visual Acuity right eye:
Visual Acuity left eye:
Visual Acuity both eyes:
Please select preferred reading medium:
Please indicate any known absences during Project STEP by day or week (application priority given to students participating in all three weeks):

Other (Specify):
NEW IN 2008
In addition to regular day programming, a residential component will be added this year during the third week of Project STEP. Each student will live in a dorm at Webster University from Sunday June 22 through Thursday June 26. Evening instruction in activities of daily living and orientation and mobility will occur in addition to guest speakers and recreation events.
Because Project STEP is hoping to recruit participants ouside the St. Louis Metropolitan area, would you be willing to host another student in your home Sunday June 8 throught Thrusday June 12 and Sunday June 15 through June 19?
EMERGENCY CONTACT INFORMATION
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
List Food Allergies:
Medications:
Medications To Be Taken At STEP:
Have you decided to attend college or vocational program?:
Have you decided,or are you considering, a career goal?:
If Yes, describe career interests:
Would you like to shadow a professional in that career?:
List all previous work (paid and non-paid) and/or volunteer experience
Company:
Position:
Company:
Position:
The following materials will be used during STEP, please mark the items YOU DO NOT HAVE:



Transportation for STEP may be available on a case by case basis. Do you want someone to contact you about transportation?:
If yes, please indicate need:
Have you had a formal Low Vision Evaluation in the past 2 years?:
If Yes, where:
If no, would you like to have one prior to or during Project STEP?:
Have you had a formal Assistive Technology Evaluation in the past 2 years?:
If Yes, where:
If no, would you like to have one prior to or during Project STEP?:
Please list all assistive technology used at home, school and community:
Please mark three to five skills you want to learn or improve during the STEP Program. Mark in the order of preference (1=highest, 5=lowest) or describe any skills not listed that you would like to pursue.
Adaptive Kitchen Skills (cutting, slicing, pouring, measuring, etc.):
Cooking Skills (stove, oven, microwave, toaster, etc.):
Daily Living Skills (vacuuming, ironing, clothes labeling, shaving, etc.):
Dining Etiquette / Personal Hygiene (utensil use, personal care, shaving, etc.):
Money Management and Budgeting:
Orientation and Mobility (cane travel, low vision aids, mass transit, etc.):
Recreation and Leisure Activities:
Tactile or Large Print Labeling (clothes, appliances, storage, organization, etc.):
Employment / Career (application completion, resume writing, interviewing, etc.):
Career Exploration / Job Shadowing:
Other (please specify):
You (the applicant) must complete the Student Self-Assessment and your Parent/Guardian or Teacher must complete the Parent/Teacher-Assessment in order for your application to be considered complete!

You (the applicant) may be required to participate in a Low Vision / Technology evaluation prior to the STEP program. Details will come upon acceptance.

DO NOT HAVE ONE PERSON COMPLETE ALL FOUR CHECKSHEETS - WE NEED UNBIASED FEEDBACK!!!

STUDENT SELF-ASSESSMENT - Adaptive Skill Area
Money Management (label, fold, etc.):
Banking Skills (checking, balancing,etc.):
Clothing Management:
Labeling and Marking:
Organization (home, school, etc):
Cooking (oven / stove, recipes, cutting):
Housekeeping / Cleaning:
Microwave / Toaster:
Laundry:
Dishwasher / Dishwashing:
Signature Writing:
Shopping (grocery store, mall, restaurant):
Health / Fitness / Diet:
Personal Hygiene (shaving, shoe tying, etc.):
Eating Etiquette:

STUDENT SELF-ASSESSMENT - Orientation & Mobility
Use of Sighted-Guide:
Negotiate unfamiliar indoor environments:
Negotiate unfamiliar outdoor environments:
Numbering Systems:
Giving / Receiving Directions:
Map Reading:
Slate and Stylus:
Telescope / Monocular (low vision):
Cane Skill – constant contact:
Cane Skill - two point touch:
Cane Skill – touch and drag:
Ascending / Descending Stairs:
Elevator / Escalator Use:
Department Stores / Mall:
Public Transportation:
Other (please specify):



PARENT/TEACHER ASSESSMENT - Adaptive Skill Area
Money Management (label, fold, etc.):
Banking Skills (checking, balancing,etc.):
Clothing Management:
Labeling and Marking:
Organization (home, school, etc):
Cooking (oven / stove, recipes, cutting):
Housekeeping / Cleaning:
Microwave / Toaster:
Laundry:
Dishwasher / Dishwashing:
Signature Writing:
Shopping (grocery store, mall, restaurant):
Health / Fitness / Diet:
Personal Hygiene (shaving, shoe tying, etc.):
Eating Etiquette:
Completed by:
Relationship:

PARENT/TEACHER ASSESSMENT - Orientation & Mobility
Use of Sighted-Guide:
Negotiate unfamiliar indoor environments:
Negotiate unfamiliar outdoor environments:
Numbering Systems:
Giving / Receiving Directions:
Map Reading:
Slate and Stylus:
Telescope / Monocular (low vision):
Cane Skill – constant contact:
Cane Skill - two point touch:
Cane Skill – touch and drag:
Ascending / Descending Stairs:
Elevator / Escalator Use:
Department Stores / Mall:
Public Transportation:
Other (please specify):



Completed by:
Relationship:
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