ITP Intake Form

Check this box if this is an International Student

International

When International Student is checked, all address and phone number fields will change to International format.

Student Contact Information

Student Name*

First Last

Preferred Nickname

Gender*

Program Start Date*

Student's Email*

If no email exists. Please use firstname.lastname@nomail.com Substitute the actual First and Last name. This is Important so we do not cause duplicates in our database.

Permanent Home Address

Street Address City State ZIP Code

International Permanent Home Address

Street Address City State / Province / Region ZIP / Postal Code Country

Student's Cell Phone*

Student's International Cell Phone*

Student's Home Phone

Student's International Home Phone

Residential Program Status:*

Day Student
Residential Student

5871 S Lowell Blvd. Littleton, CO 80123

McGeorge Mountain Terrace Apartment Number*

Student's Date of Birth*

Medical History

Local Primary Physician's Name

Medical Insurance Provider*

Preferred Hospital

Primary Cause of Blindness*

Explain any Other Disabilities and/or Health Problems

Explain any on-going treatments

Please list any alergies to medications

Medication	Symptoms of your allergic reactions

Please list any food allergies

Type of food	Symptoms of your allergic reactions

Other Allergies

Dietary Restrictions

Activity Restrictions

Explain Hospitalizations (last 5 years)

Current Medications*

Medication Name	Dose	Frequency	Reason for taking	Date started	Self Administered?	If No please explain

Emergency Contacts

How many Emergency Contacts does the student have?*

0
1
2

Emergency Contact #1

Emergency Contact #1 Name*

First Last

Emergency Contact #1 Address

Street Address City State ZIP Code

Emergency Contact #1 International Address

Street Address City State / Province / Region ZIP / Postal Code Country

Emergency Contact #1 Email*

If no email exists. Please use firstname.lastname@nomail.com Substitute the actual First and Last name. This is Important so we do not cause duplicates in our database.

Emergency Contact #1 Cell Phone*

Emergency Contact #1 International Cell Phone*

Emergency Contact #1 Home Phone

Emergency Contact #1 International Home Phone

Emergency Contact #1 Work Phone

Emergency Contact #1 International Work Phone

Emergency Contact #2

Emergency Contact #2 Name*

First Last

Emergency Contact #2 Address

Street Address City State ZIP Code

Emergency Contact #2 International Address

Street Address City State / Province / Region ZIP / Postal Code Country

Emergency Contact #2 Email*

If no email exists. Please use firstname.lastname@nomail.com Substitute the actual First and Last name. This is Important so we do not cause duplicates in our database.

Emergency Contact #2 Cell Phone*

Emergency Contact #2 International Cell Phone

Emergency Contact #2 Home Phone

Emergency Contact #2 International Home Phone

Emergency Contact #2 Work Phone

Emergency Contact #2 International Work Phone

VR Counselor

Is the student’s VR Counselor the same as at the time of referral?*

Check “No” if referral was not made with our On-Line form.

Yes
No

VR Counselor's Name*

First Last

VR Counselor's Email*

If no email exists. Please use firstname.lastname@nomail.com Substitute the actual First and Last name. This is Important so we do not cause duplicates in our database.

VR Counselor's Phone*

VR Counselor's Fax

Additional ITP Intake Information

Student Policies Read and Signed*

Not Signed
Signed

Social/Media Policy Read and Signed*

Agree
Decline

Medical from VR Complete?*

Release of Information for VR*

Not Sent
Sent

Covid-19 Form*

Signed
Not Signed