Apply For Our 2023 Summer Program!

Student Information

Student Name*

First Last

Student Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Student Cell Phone*

Phone

Students Email*

Date of birth*

Gender:

Male
Female
Other

Primary Cause of Blindness*

Explain any Other Disabilities and/or Health Problems

Race/Ethnicity: How would the student describe him/herself?

Please check all that apply.

American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White

Parent/Guardian

Relationship to Student*

Parent/Guardian Name*

First Last

Parent/Guardian Email*

Parent/Guardian Phone Number*

Parent/Guardian Home Phone

Parent/Guardian Address

Same as Student

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Does the student have a VR Counselor?*

Yes
No

Vocational Rehabilitation Counselor’s Name*

First Last

Vocational Rehabilitation Counselor’s Phone

Vocational Rehabilitation Counselor’s Fax

Vocational Rehabilitation Counselor’s Email*

Vocational Rehabilitation Counselor’s Address

Street Address Address Line 2 City State ZIP Code

Has the student’s Rehabilitation Counselor approved funding for a summer course (or courses) at CCB?

Yes
No

Academic Information

What is the name of the school the student is attending?*

What grade will the student be in this fall?

Does the Student have a TVI?*

Yes
No

Name of TVI*

First Last

TVI Phone

TVI Email*

Can we contact TVI?*

Yes
No

Where should we send follow-up communications?*

Before pressing the submit button, please review all information, especially spelling of names, phone numbers and e-mail addresses to be sure all are correct.