Youth Transition: Photography for All Application

Contact Information

Student Name*

First

Last

Address*

Street Address

Address Line 2

City

State

ZIP Code

Date of Birth*

Gender*

Male
Female
No Response

Student Phone*

Student Email*

Parent/Guardian Name*

First

Last

Parent/Guardian Name 2

First

Last

Parent/Guardian Phone*

Parent/Guardian Phone 2

Parent/Guardian Email*

Parent/Guardian Email 2

Schooling Information

School Name*

Current Grade in School*

Graduation Year*

Vision Teacher Name*

First

Last

Vision Teacher Email*

O&M Specialist Name*

First

Last

O&M Specialist Email*

Participant's Diagnosed Visual Impairment*

Visual Acuities*

Right Eye	Left Eye	Both Eyes

Preferred Reading Medium*

Regular Print
Large Print
Braille (Hard Copy)
Electronic

Emergency Contacts

Emergency Contact Person 1*

First

Last

Relationship*

Phone*

Emergency Contact Person 2*

First

Last

Relationship*

Phone*

Medical Information

Medical Conditions (may write None)*

(Ex: Cerebral Palsy, Seizures, Autism, Diabetes, etc.)

Does applicant take prescription medications?*

Yes
No

Does applicant require a nurse or another person to administer medication?*

Yes
No
N/A

Food Restrictions or Special Dietary Needs (may write None):*

Additional Information

Does applicant have an open case with Bureau of Blind Services?*

Yes
No

If yes, please provide counselor's name.

First

Last

Phone

Email

Please list all assistive technologies used daily (may write None).*

Ex: Magnifier, Monocular, iPad, Braille Display, etc.

Please ensure you meet the following:*

I have low vision
I have the ability to travel throughout the city of Chicago, up to 5 hours
I can meet at The Chicago Lighthouse, 1850 W Roosevelt Rd, Chicago
I am eligible to work
I understand my TVI/O&M will be contacted as a reference

RELEASE FORMS

Authorization for Treatment of Participant – Consent, Release and Covenant

The undersigned parent/guardian represents to The Chicago Lighthouse that the minor named below is in his and/or her legal custody and control; that the undersigned desires said minor to participate in the programs of The Chicago Lighthouse; and that for purposes of said participation the undersigned agrees, authorizes and states as follows:

In case of medical or dental need or emergency, I (we) understand every effort will be made to contact parents/guardians of minors. (sign participant name)*

I (we) authorize The Chicago Lighthouse and its officers or staff employees as agent(s) for the undersigned
to obtain and consent to any X-ray examination, anesthetic, medical, dental, surgical diagnosis, treatment and hospital
care which is deemed advisable, and is to be rendered to said minor under general or specific supervision of any surgeon
licensed under the provision of the Medical Practice Act or the medical staff of a licensed hospital or by a dentist licensed
under the provisions of the Dental Practice Act, whether such diagnosis of treatment is rendered at the office of said
physician or dentist or at the said hospital. I (we) also understand and agree that any and all such medical, dental, hospital or similar expenses incurred in the treatment of my (our) child will be borne by myself (ourselves). We understand that no representation of such coverage exists or is intended by this form.
It is understood that this authorization is given in advance of any specific medical or dental diagnosis, treatment or care being required but is given to provide authority and power on the part of The Chicago Lighthouse (as aforesaid) as my (our) agent(s), to give specific consent to any and all such diagnosis, treatment or care which a licensed physician or dentist in the exercise of his/her best judgment may deem available. This authorization shall remain effective while the minor is enrolled in any Chicago Lighthouse for People Who Are Blind or Visually Impaired program, unless sooner revoked in writing and delivered. The undersigned further releases The Chicago Lighthouse, and its officers, agents and employees, from any and all legal responsibility for accidents or sickness occurring during or related to the period of time said person is a participant in programs of The Chicago Lighthouse. I (we) further agree and covenant (for valuable consideration, receipt of which is acknowledged) that neither said person nor I (we) will institute any suit or action of damage, loss or injury of any kind, whether to person or property, whether to me (us), individually, or as parents/guardians relating to the programs or activities of The Chicago Lighthouse in which the minor participates.

Release of Information*

Yes
No

I hereby authorize and give permission to The Chicago Lighthouse to obtain and/or provide information to school district(s) , optometrist/ophthalmologist and/or Bureau Blind Services (BBS) for programming and collaboration regarding the participant listed below.

Off-Site Activities*

Yes
No

I hereby authorize and give permission for the participant identified below to participate in any off-site activities as a part of the selected programs. I understand such activities will be provided in a vehicle owned or rented by The Chicago Lighthouse and will be accompanied by a Chicago Lighthouse staff member.

Transportation*

Yes
No

I hereby authorize and give permission to The Chicago Lighthouse to provide transportation for the participant identified below during Chicago Lighthouse programs for purposes of participating in programming and off- site activities.

I have read this release and agree to all stated. When Submitted electronically, your printed name serves as your signature. This is VALID FOR ONE CALENDAR YEAR. (Sign participant name if over 18 OR parent/guardian of a minor)*

Date*

Comments

This field is for validation purposes and should be left unchanged.