The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Vocational and Educational Services for Individuals with Disabilities
New York State Resource Center for Visually Impaired
2A Richmond Avenue, Batavia, NY  14020
(585) 343-5384 / FAX (585) 343-0652

2008-09 REGISTRATION FORM FOR CHILDREN CLASSIFIED
AS LEGALLY BLIND

 (Central Visual Acuity of 20/200 or less in the better eye after correction or
a field of vision restricted to a 20 degree arc or less)

Available in Word for Printing

Name of Student ______________________________ Date of Birth ________________
                                  (Last)            (First)            (M.I.)                          Month  Day   Year           

Sex:   Male   [ ]          Female      [ ]                      Grade*____________

District or Agency where individuals receive special services for the visually impaired during school hours:

Name:________________________________________________ Public [ ] Private [ ]

Address: _______________________________________  Phone: (         ) ___________
                                                                                                            
                                                                                               Fax:  (        )  ____________

                                                                                                E-mail: ________________

District of Residence (Home District)  

Student’s VISUAL ACUITY based upon an existing report of an eye specialist (optometrist, oculist or ophthalmologist)
 

Vision after correction*            RIGHT EYE    box         LEFT EYE box
 

Indicate the student’s ONE PRIMARY AND ALL SECONDARY READING MEDIUMS in the spaces at the right:

VISUAL READER – uses regular OR large print . . . . . . . . . . . . . . . . .
V
 1st
[ ]
BRAILLE READER – uses braille . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .
B
   2nd
[ ]
AUDITORY READER – uses reader OR recorded material . . . . . . . . . .
A
  
[ ]
PREREADER – readiness level OR medium undetermined . . . . . . . . . . .
P
  
[ ]
NONREADER – does not fall into any above category . . . . . . . . . . . . . . .
N
  
[ ]

                                               
*See enclosures for appropriate coding and/or instructions

 PERSON COMPLETING THIS FORM

Name                                                                               Title                                                    

School District                                                                 Phone (        )

E-mail                                                                                                Fax (        ) 
 

REVISED 10/07