STARS

Specialized Technology and Adaptive Resources for Students
A Joint Program of Lighthouse for the Blind and St. Louis Society for the Blind and Visually Impaired


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

If you print and send this Regular Mail, please send to:
Brenda Wendling
St. Louis Society f/t Blind and Visually Impaired
8770 Manchester Rd.
St. Louis, MO 63144
Phone: 314-301-7374
FAX: 314-968-9003

Application for Services

Date:
I/We are applying for services for the following program:

How did you hear about the program?
Student's Name:
Date of Birth:
Street Address:
City:
State:
Zip:
Student Email: (REQUIRED) If you don't have an email write your name:
 
Phone Number:
Parent/Guardian:
Work Number:
Address:
Phone Number:
Email Address:
Emergency Contact Name:
Phone Number:
Alternate Number:
Emergency Contact Name:
Phone Number:
Alternate Number:
Eye Condition(s):
Eye Doctor(s):
Reading Mode:
If "Other" reading mode, please indicate:
Other Health Conditions:
List Any Food Allergies:
Vision Teacher:
Grade:
School District:
School:
School Street Address:
City:
State:
Zip:
Does the student use:

Reason for Applying:
Has the student received or applied for any equipment from The Lighthouse for the Blind?
If so, what?
If applying for Technology Assistance, does the student use:




If "Other", what does the student use?
If applying for Activities of Daily Living, please rank the areas of most need, 1 - 3:
Cooking/Kitchen:
Household/Bedroom Organization:
Hygiene/Self-care:
Does the student do any of the following:






If "Other", what else?
Does the student have an open case with Rehabilitation Services for the Blind (Missouri) or Bureau for the Blind (Illinois)?
If so:
Staff Person:
Phone:
Office Location: