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 address then write, I do not have an email, 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 one write: I do not have an email
|
Phone Number:
|
Parent/Guardian:
|
Work Number:
|
Address
|
Phone Number:
|
Email Address:
|
Eye Condition(s)
|
Eye Doctor(s)
|
Reading Mode:
|
If "Other" reading mode, please indicate
|
Other Health Conditions
|
Vision Teacher:
|
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 yes, what?
|
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 elso?
|
| 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:
|
|