School Year Short-Term Programs Referral Form 2023-2024

Formal Request to Attend a School Year Short-Term Programs Class

Attention: Only one referral form is required for each student per school year. Once you fill out a referral for a student for this school year (2023-2024) you do not need to fill out subsequent referrals.

If you have already filled out a referral for this student for 2023-2024, and you would like to add a class, you please send an email to: stp-admissions@tsbvi.edu.
Please include your student's Name, Date of Birth & the class(es) he/she would like to attend.

-Thank You

GENERAL INFORMATION

Before making a referral, please remember that all Short-Term Program classes are for students who are on or close to grade level. This includes the weekend independence classes.

Before you submit this proposal, please be certain that the student, family and school are committed to the requested classes.

Referrals must be made by a member of the local school district. This is usually the student’s Teacher of the Visually Impaired (TVI). Parents cannot refer to these classes except through their local district.

Please ensure that the student's name and date of birth are correct, when coordinating travel for your student it is essential that we have the correct spelling of a student's name and an accurate date of birth.

PLEASE NOTE: If you have not received an email confirmation within 30 minutes after sending a referral, please send a follow-up email to: (stp-admissions@tsbvi.edu).

Important: All fields marked with are required.

Student Information

First Name (birth name)

Nickname

Last Name

Student Email (List 1 email only)

Texas Unique Id (P.E.I.M.S. or T.S.D.S. Number)

Gender

Date Of Birth

Ethnicity

Current Grade

District

Student's School District City

Guardian Information

Primary Guardian's First Name

Primary Guardian's Last Name

Best Phone to Reach Guardian

Guardian's Preferred language (if different than english)

Street Address

City

State

Zip

Guardian's Email Address

Teacher of the Visually Impaired (TVI) Information:

TVI's First Name

TVI's Last Name

Best Phone To Reach You

Alternate Phone Number

Fax Number

Email Address (List 1 email only)

Please review our class descriptions before selecting classes: Class Descriptions (opens in new window)

Note: You must select at least one class from Fall or Spring

Select Classes for Spring 2024 - CHECK ALL CLASSES DESIRED

Individualized Instruction Ongoing

Algebra I (SBOE Credit) - Spring January 8 - May 23

High School Access to Academic Skills- Spring (grades 9-12) January 8 - 12

Game of Life (grades 6-9) January 18 - 21

Elementary Access to Academic Skills- Spring (grades 3-5) January 28 - February 2

Magical World of STEAM (grades 4-5) February 8 - 11

Junior Access to Academic Skills- Spring (grades 6-8) February 19 - 23

In the Driver’s Seat: An Introduction to Safe Driving with Low Vision (grades 9-12) March 1 - 3

High School Independence Weekend: Outdoor Challenge (grades 9-12) March 21 - 24

City Travel for COMS and Their Students (grades 7-12) April 4 - 7

In Your Element Part 2 (Access to Chemistry) (grades 9-12) April 14 - 18

Algebra I Exponential, Quadratic, & Radical Functions (gr. 8-12) April 14 - 18

Health and Well-Being: An introduction to Human Sexuality (grades 5-7) April 21 - 25

Elementary Independence Weekend: Outdoor Exploration (grades 3-5) May 2 - 5

High School Independence Weekend: In the Heart of Texas (grades 9-12) May 16 - 19

Student needs information

What subject do you feel your student most needs to focus on in this session?

Please tell us more about your students proficiency/needs indicated in the previous question

City Travel information (only applicable for city travel classes)

Coms First Name

Coms Last Name

Coms Phone Number

Coms Email

Vision

What is the student's primary learning medium?

Student reads best WITH optical devices and print/font size (enter "na" if no data available)

Student reads best WITHOUT optical devices and print/font size (enter "na" if no data available)

Distance Vision Left Eye (OS)

Distance Vision Right Eye (OD)

Near Vision Left Eye (OS)

Near Vision Right Eye (OD)

Eye Condition or Diagnosis

Prognosis

If student has visual field loss, please describe (e.g., peripheral loss, central loss, lower or upper field loss – including degree if known)

Math Academic Level

What is this student's tested MATH grade level?

Which Math STAAR did the student take most recently?

Did the student pass?

Reading Academic Level

What is this student's tested READING grade level?

Which Reading STAAR did the student take most recently?

Did the Student pass?

Support Services

Hours per week spent in Pull-out for VI / O&M services

Hours per week spent in Other services (Resource room, self-contained special ed classroom, speech, etc.)

Describe Hours per week spent in Other services

Hours per week spent in Regular Classroom without support

Hours per week spent in Regular Classroom with support

Describe support

Restrictions for Participating in Physical Activity

Does the student have any RESTRICTIONS for participating in PHYSICAL ACTIVITY?

Describe the activities

Additional Information

Provide any additional information that would assist TSBVI staff to better understand your student: (Consider your student in an unfamiliar setting with an unknown teacher and classmates)

Note: Please print and keep a copy of this referral.

This will help if your referral is not received due to some technical issue.

The purpose of this referral is to help us evaluate the appropriateness and general direction of services at the referral stage. When we receive a referral, we will:

let you know we got it within 30 minutes, so contact us if you don’t hear back
put your student’s name on the list for all appropriate classes requested
wait until two months before each class to determine who is accepted, and then
contact you to let you know if your student is accepted or on the waitlist.

Before you submit this proposal, please be certain that the student, family and school are committed to the requested classes. Help families understand that all our classes are highly educational and competitive, including the weekends. When students drop out after being accepted, a lot of work is done unnecessarily. Of course we understand that illness would prevent attendance. We greatly appreciate your help with this!