DBVI_R 2024 Universal Application
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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.


Please enter the first and last name of the student:
Please indicate the name and relationship of the person completing this form:
DBVI Student Program List
I'm interested in participating in the following programs
Prior trainings
Has the student ever attended any of the following DBVI training programs?
Section 1: Let's Get to Know You!

Student Information
Student’s Mailing Address (please include street, city, state and zip code):
Student’s cell number (if the student does not have a cell phone, please enter N/A):
Student’s email address (this is the email address we will use to communicate with the student during programs. Please ensure this is the student's email address and not the parent's - if the student does not have an email address, please leave it blank:
Date of birth:
Grade ('24-'25 academic year):
Expected Graduation Year
Name of current school and location
Vocational Rehabilitation Counselor name (mark N/A if unknown):
Education Coordinator name (mark N/A if unknown):
Teacher for the Vision Impaired name (mark N/A if unknown):
Success Tools:
Student accommodations
Do you require the following student accommodations?
Please provide details regarding the requested accommodations:
Section 2: Parent / Guardian Information
Parent/Legal Guardian #1 Name:
Parent/Legal Guardian #1 Address:
Parent/Legal Guardian #1 Phone Number:
Parent/Legal Guardian#1 email address:
Parent/Legal Guardian #2 Name:
Parent/Legal Guardian Phone (Cell #2):
Parent/ Legal Guardian #2 address, if different from above:
Parent/Legal Guardian #2 email address:
Parent Accommodations
Parent Accommodations for Family Programs:
Please provide details regarding the requested parent accommodations:
If you are student’s legal guardian, do you have a copy of the court documents demonstrating that?
If yes, please fax a copy of the legal guardianship court order to DBVI, Attention: Felicia Williams at (804) 371-3174.

If no, please explain:
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)
I have sole legal custody of applicant (please provide name):
Emergency Contact Information
Emergency contact name, phone number and relationship to student:
Emergency contact address:
If the student is dismissed from a DBVI residential program or during any emergency closing, the student must be picked up within 8 hours and will return to the following address (if different from above):
Section 3: Student Medical Information
Our 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)
List Medical Insurance provider and policy number for medically necessary services and/or medical emergencies. Please have your student bring a copy of their insurance cards when participating in the residential programs. (If none, state N/A)
Medical Diagnosis
Have you been treated for any of the following in the last two years?
Please describe other conditions not listed above:
Does the student have any psychological or emotional differences that may affect their ability to self care/self regulate?
If yes, briefly describe the psychological and/ or emotional issues:
Activities of Daily Living
Do you receive assistance at home with Eating, Dressing, Bathing, Using the Bathroom, Bowel Care, or Bladder Care? If yes, briefly describe activity restrictions.
Is the student able to actively participate in group settings? If no, please explain.
Does the student have diabetes?
Diabetes plan
If yes, please check all that apply about the student's diabetes management plan:
If there is a chronic medical diagnosis, do you have an established management plan? If so, please explain. (Such as: uses an inhaler with exertion, requires extra time to orient to new situations, requires rest in a quiet room when experiencing migraine symptoms, needs to stay hydrated to prevent seizures, etc):
Mobility
Do you use a manual wheelchair, Power Chair, or Scooter? If so, can you transfer independently, sit in wheelchair, or propel yourself long distances? Please describe:
Please describe any allergies. (Include medications, insects, environment, food, etc.)
List all prescription and over-the-counter medications student is currently taking, including the dosage, the time of administration, and the reason for the medication. Include any medications taken by mouth, injection, or inhaled. (If the student takes no medications enter N/A):
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):
Additional medication info
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
Special accommodations
Student Signature:
Custodial Parent/Guardian Signature:
Date:
What do you enjoy doing in your free time?
What occupations or career pathways is the student interested in?
Describe any previous work and/or volunteer experience
Section 4: Releases

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.
Applicant’s Signature:
Custodial Parent/Legal Guardian Signature:
Date:
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.
Student Signature:
Custodial Parent/Guardian Signature:
Date:
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.
Student Signature:
Custodial Parent/Guardian Signature:
Date:
Once you submit this application, you will see a blue screen which indicates the application was completed.