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:
Please include your student's Name, Date of Birth & the class(es) he/she would like to attend.

-Thank You


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: (

Important: All fields marked with Required information are required.

Student Information

Guardian Information

Teacher of the Visually Impaired (TVI) Information:

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 Fall 2023 - CHECK ALL CLASSES DESIRED
Select Classes for Spring 2024 - CHECK ALL CLASSES DESIRED
Student needs information

City Travel information (only applicable for city travel classes)

Math Academic Level

Reading Academic Level

Support Services
Restrictions for Participating in Physical Activity
Additional Information

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:

  1. let you know we got it within 30 minutes, so contact us if you don’t hear back
  2. put your student’s name on the list for all appropriate classes requested
  3. wait until two months before each class to determine who is accepted, and then
  4. 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!