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Vocational and Educational Services for Individuals with Disabilities (VESID)
Special Education and Vocational Rehabilitation Services

The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of Vocational and Educational Services for Individuals with Disabilities
Special Education Quality Assurance

APPLICATION TO THE COMMISSIONER OF EDUCATION
FOR APPROVAL FOR AN EVALUATION TO ATTEND A
STATE-OPERATED SCHOOL
PHC-10

Updated January 2008

Available in Word Format for printing

 

State-Operated School (indicate which school you are applying to):

New York State School for the Blind (NYSSB)   1

New York State School for the Deaf (NYSSD)   1

 

                                                                                         INSTRUCTIONS

 

  1. Please PRINT or TYPE the information on this application.
     

  2. Submit the following medical documentation with this application:

       For a child who is Blind (a minimum of one of the following documents must be submitted):

For a child who is Deaf:

  1. Submit the following school/educational information with this application (if available):

  1. Send a completed application and required documentation to the attention of:

Regional Associate

VESID - SEQA

Nondistrict Unit

One Commerce Plaza, Room 1623

Albany, NY 12234

(518) 473-1185

Attn: PHC-10 Application

 
 

NOTE:  During the processing of this application it is necessary that your child remain in his or her current placement to ensure the continuity of his/her educational program.

 

For further assistance in completing this application please contact the appropriate Office listed above.

 

 

  Date of Application: ____________

  1. Child'sName: _____________________________________

  1. Date of Birth:        /       /     

                                   (Last)                          (First)    

  1. Gender 1F       1M     
    
  1. Parent(s)/Guardian(s) Name(s):                                                                                                            

 
  1. Address:                                                                                                                                                                                                         (Street)                                                       (City)                          (State)                 (Zip Code)

 County of Location:                                                                    

Telephone Number: (      )                                    Email Address: ______________________

  1. Indicate the dominant language used in the home:                                                                    
  1. Indicate child's primary disability (check only one):

Blind.......................................................... 1

Legally Blind ............................................. 1

Deaf/Blind ............................................. . 1

Deaf..................................... 1

Functionally Deaf.......................................... 1

 

  1. If child has multiple disabilities (check all that apply)

Autistic ................................................... 1

Orthopedically Impaired ........................................ 1

Emotionally Disturbed ...........................1

Other Health Impaired ............................................ 1

Hearing Impaired ....................................1

Speech Impaired....................................................... 1
Learning Disabled................................... 1 Traumatic Brain Injury .............................................1

Mentally Retarded........................... ........1

Visually Impaired ..................................................... 1
  1. Local School District of Residence:  ________________________________________

Address:  ____________________________________________________________________                              

                       (Street)                                                                                     (City)                     (State)                   (Zip Code)
 

 Telephone Number: (      )                                               Fax: (      )
  1. Indicate current educational placement of child.

School Name:                                                                                 Phone: (      )                                  

Program Administrator:                                                                                                                                             

Address:                                                                                                                                                                       

  (Street)                                                (City)                          (State)                            (Zip Code)
 
  1. Person completing this application (If different than Parent or Guardian):

Name:                                                                                                        

Title/Agency:                                                                                              

Address: ______________________________________________

Telephone Number:                                                                 Email address: __________________

 
  1. ______________________________________________________________________________
    Signature of Parent or Guardian                                                          Date

 

SED Use Only:

 

  Initials

1Received - Date:______________________________

____________
   
1Approved (Regional Associate) - Date: ________________ ____________

SED Action:

1Send Attachment D: Referral

1Original to : Parent

1Copy to: CSE Chairperson

1Copy to: State-operated School

Date: __________________________________

 
   
1Not Approved (Regional Associate) - Date: ________________ ____________

SED Action:

1Send Attachment G or G-1: Rejection

1Original to : Parent

1Copy to: CSE Chairperson

1Copy to: State-operated School

Date: __________________________________