|
|
Virginia Department for the Blind and Vision Impaired Universal Application
To participate in these opportunities, students must be receiving vocational rehabilitation services or determined potentially eligible so that funding can be reserved for the selected activities.
Please contact your Education Coordinator, Vocational Rehabilitation Counselor, or call (800) 622-2155 to be connected to a Vocational Rehabilitation Counselor in your area.
If you have additional questions and want information regarding these services, please contact:
Felicia Williams, Pre-employment Transition Specialist, at (804) 371-3164 or
Tish Harris, Pre-ETS and Career Pathways Coordinator at (540) 294-1215
Visit our website at https://www.dbvi.virginia.gov/students.htm for updates and more information.
This application includes the following:
• Universal Application
• Waiver and Liability Form
• Student Contract
• Photographic -Recording Release
*LIFE requires a separate application and supporting documents which are due by April 1, 2024. Please see your vocational rehabilitation counselor for more information to complete this application. Determinations on acceptance for LIFE will be provided by April 15, 2024. Please note if you apply for Life, your application for programs that occur between July 7, 2024 and August 4, 2024 will be processed after a determination has been made for the LIFE program.
|
|
Section 1:
Let's Get to Know You!
Student Information
|
Section 2: Parent / Guardian Information
|
If you are student’s legal guardian, do you have a copy of the court documents demonstrating that?
|
|
If the parents have joint custody, please fax the court custodial order to DBVI Attention: Felicia Williams at (804) 371-3164.
If the student’s parents have joint custody of the student, all forms and documentation pertaining to residential programs must be signed by both parents.
|
______ and ______ have joint legal custody of student. (please provide names)
|
|
Emergency Contact Information
|
Section 3: Student Medical InformationOur student's health and safety are of utmost importance to us. We require medical information to be considered for Residential Programs.
(2024 Residential Programs- Blind Design,
Cyber Space,
Careers in Action, Launching Point, and Entrepreneurship Development for Gainful Employment)
|
Does the student have diabetes?
|
|
DBVI staff cannot administer any prescription or over-the-counter medications. Instead, the student must self-administer all medications. Please describe the medication management plan for the student while attending DBVI Residential Programs (select all that apply):
|
Please choose "yes" to indicate that you understand and agree to the following:
1. Student will bring all prescription and over-the-counter medications in the original bottle or container, taking into consideration headaches, cold/allergy symptoms and commonly occurring aches and pains
2. Student will bring enough medication for the entire length of the residential program, or will have a plan established to ensure student receives any needed refills
3. Student will bring all needed medical supplies, such as diabetes supplies, incontinence supplies, cpap machine, walker, etc.
4. Student will bring all needed personal hygiene supplies
5. Student will bring their medical insurance card(s) if applicable
|
What occupations or career pathways is the student interested in?
|
|
RELEASE, WAIVER OF LIABILITY, ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
|
In consideration of participation in the Virginia Department for the Blind and Vision Impaired
(DBVI)sponsored activities, I represent that I understand the nature of the activity in which I
am participating, and that I am qualified, in good health, and in proper physical condition to
participate in such activity. I acknowledge and represent that if I believe activity conditions are
unsafe, I immediately will discontinue participating in the activity.
I fully understand that this activity involves risks of serious injury, including but not limited to
permanent disability, paralysis, and/or death, and damage to property, which may be caused by my
own actions or inactions, the actions or inactions of others participating in the activity, the
conditions in which the activity takes place or the negligence of the “Releasees” named below, and
that there may be other risks not known or readily foreseeable at this time; and I fully accept and
assume all such risks and all responsibility for losses, costs, and damages that I incur as a result of
my participation in the activity.
In consideration of being allowed to participate in the activities, I hereby release, discharge, and
covenant not to sue DBVI, its administrators, founders, directors, agents, officers, volunteers and
employees, and other participants in the activity (each considered to be one of the “Releasees”
herein) from any and all liability, claims, demands, and responsibility relating to injuries, death or
damages to me or my property, which arise from or are caused or alleged to be caused by my
participation in the activity, including claims, losses or damages caused or alleged to be caused, in
whole or in part, by the negligence of the Releasees or otherwise, including negligent rescue
operations. I further agree that if, despite this release, waiver of liability, and assumption of risk, I
or anyone on my behalf, makes a claim against any of the Releases, I will indemnify, save and hold
harmless each of the Releasees from any loss, liability, damages or costs which any may incur as
the result of any such claim.
I have read this Release, Waiver of Liability, Assumption of Risk, and Indemnity Agreement
and have signed freely and without any inducement or assurance of any nature, intending it to be a
complete and unconditional release of all liability to the greatest extent allowed by law. I agree
that if any portion of this agreement is held to be invalid, the balance shall continue in full force
and effect. This form shall be in force and effect from January 2024 through December 2024.
|
Student Learning Contract
Our primary goal is to offer an exciting and unique learning experience, while providing a safe and productive environment. We ask that parents and students review this list together. Our expectations:
Students shall:
1. If the student is attending in person, they will only leave the dorm with an adult staff or mentor after notifying academy coordinator or dorm supervisor. (You will be notified of the appropriate staff to contact for the program you are attending.) 2. If attending virtually, respectful and appropriate communication is required.
3. Let an instructor or staff know about any concerns. 4. Treat all students and staff with courtesy and respect. 5. Not use cell phones during instructional or meeting times unless instructors have indicated cell phone use is acceptable during that portion. 6. Not bring on campus or use tobacco products or illegal substances such as drugs or alcohol. 7. Not engage in any behaviors that create unsafe or uncomfortable environments for others. 8. Actively participate in all aspects of the program 9. Follow any mask and safety protocols that may be in place at the time.
10. DBVI programs allow students to connect with their peers. We encourage networking. However, we ask students not to share their peers contact information without their permission.
|
Please sign below to certify that you have read and understand the student expectations. Students under the age of 18 must have a parent or guardian signature. Further, please be aware that failure to follow these policies can result in expulsion from the program.
|
Virginia Department for the Blind and Vision Impaired
Photographic/Recording Release
|
I grant and assign to the Department for the Blind and Vision Impaired, its agents, employees, designees, successors or assignees, all my rights, title and interest to photographic/recorded reproductions of me/my voice and consent that such photographs/recordings may be used in any manner for advertising and publicity. I further grant permission for the copyright of such photographs/recordings and consent that they may be reproduced either partially or in composite, or distorted in character or form, in conjunction with other photographs/recordings, names and reproductions made through any media. DBVI staff and individuals participating in DBVI sponsored programs may record lecture notes during sessions for content. I have read the above statement and am familiar with its contents.
|
|