Wisconsin Center for the Blind and Visually Impaired

Wisconsin Center for the Blind and Visually Impaired Tony Evers, PhD, State Superintendent Wisconsin Department of Public Instruction Registration Form Braille Challenge & Braille Olympics February 15-16, 2018 (Snow date, March 1-2) Check the event(s) attending: Braille Challenge Braille Olympics Student Name: Age: Grade: M F Home Address: City: State: Zip Code: Parent/Guardian Name: Address (if different): City: State: Zip Code: Home phone Cell phone Email: Work phone How can we best reach you? Emergency Contact Information: Who can we contact if we can't reach you in an emergency? Name: Relationship: Home phone: Cell phone: Work phone: Vision Teacher: Email: Phone: Reading/Learning Media: Braille Large Print Standard Print Audio Print w/magnification (magnifier type and power): Other (please explain): O&M and Travel Aids: Cane Dog Guide Wheelchair Sighted Guide Monocular (power): Hat/Visor other: Please indicate Braille reading level: Uncontracted OR Contracted Student s Name 1 of 10

Following grade levels are required for the Braille Challenge only! Apprentice, (Grades 1 and 2) Freshman, (Grades 3 and 4) Sophomore, (Grades 5 and 6) Junior Varsity (Grades 7, 8 & 9) Varsity (Grades 10, 11 and 12) Students at the Sophomore, Junior Varsity and Varsity levels for the Braille Challenge will use a Victor Reader Stream for part of the test. These students must be familiar with the operation of this device. Requesting Student On-Campus Overnight Accommodations for: Wednesday, February 14 Thursday, February 15 Does the student need accommodation for a disability (accessible bathroom, elevator, etc.)? If yes, please explain. Meals attending (Student): Wednesday: DINNER Thursday: BREAKFAST LUNCH DINNER Friday: BREAKFAST LUNCH Please indicate your student s shirt size: (shirts are free of charge for students) Child Sizes: small medium large Adult Sizes: small medium large extra-large 2X 3X Chaperone Information Parents and/or teachers are asked to serve as chaperones. This will assist us in providing a safe and fun activity for all involved. Please plan to assist WCBVI staff in the supervision of the participants. There will be no charge for lodging for either students or chaperones. All participants will be housed on the WCBVI campus. All students must have a pre-arranged chaperone present. Each parent/school is responsible for chaperoning their student(s) while on campus unless alternate arrangements are made in advance. Each chaperone may be responsible for no more than three students. Please call with questions. All adults, except teachers who are currently working for a school district, must pass a criminal background check. Any adult who did not complete and pass a background check will NOT be able to stay on campus. These must be re-done each year! Form is on page 8. These may take as much as a month to process. Please get them in early! Name: Relationship to student: Address: City: State: Zip: Home Phone: Cell Phone: How do we contact you while you are here on campus? Requesting Chaperone On-Campus Overnight Accommodations for: 2 of 10

Wednesday, February 14 Thursday, February 15 Housing preference: Child in room with me Child in room with other student(s) No preference Does the chaperone need accommodation for a disability (accessible bathroom, elevator, etc.)? If yes, please explain. Meals attending (Chaperone): Wednesday: DINNER Thursday: BREAKFAST LUNCH DINNER Friday: BREAKFAST LUNCH Other meals: Chaperones do not need to pay for meals, your name tag is your meal ticket. Other family guests should purchase meal tickets in the Business Office (open 8:00-4:30) at a cost of $4.50 per person per meal. In order to have the correct amount of food prepared, please RSVP here or by phone no later than February 1. Please list the names of any guests and which meals they will be attending. Additional Shirts Chaperones and family members are welcome to order shirts, but must include $15 for each shirt with the registration form or they will not be ordered. (Make checks out to WSBVI.) Adult sizes: Small Medium Large 2X 3X Students and chaperones should bring their usual clothing and personal items. All who are staying in the dormitories need to bring a sleeping bag, pillows, and towels. Medication and any special diet should be kept and administered by the student s chaperone. Thursday afternoon is open swim. If students would like to participate, they should be sure to bring their swim suits and towels. While a lifeguard will be present, chaperones must be present to assist their student in the pool area as needed. Wisconsin s Regional Braille Challenge is a Preliminary Contest Round and part of the National Braille Challenge sponsored by the Braille Institute of America in Los Angeles, California. WCBVI will pay for up to two finalists (and one chaperone each) from Wisconsin to attend. Each student is scored on his or her performance, and the top sixty students in the country are invited to a Final Competition in Los Angeles, California, June 2018. Students will test in the following categories: Apprentice, grades 1-2, (uncontracted, contracted); Freshman, grades 3-4; Sophomore, grades 5-6; Junior Varsity grades 7-9, Varsity grades 10-12. All contests will be in Unified English Braille (UEB). Those at Sophomore level or above will use the Victor Reader Stream for the speed and accuracy tests. Students must be familiar with and able to use this device. Visit the Braille Challenge website at www.braillechallenge.org for sample tests, or for more information about the Regional and National competitions. Health Form 1 Insurance Coverage: Student s Name 3 of 10

We are covered by an insurance plan (see below) We are covered by Medical Assistance (see below) We do not have medical insurance Insurance Plan Coverage (please PROVIDE a copy of insurance card): Insured s (Employee) Name: Employer: Location: Name of Insurance Company: _ Insurance Company Address: ID #: Group #: Contract #: Effective Date of Coverage: Medical Assistance Coverage (MA) (please provide a copy of MA card): Forward #: ID #: Parental Medical/Emergency Authorization: I understand that I am responsible for full payment of medical services and medication prescribed for my child while at WCBVI (Wisconsin Center for the Blind and Visually Impaired). As the parent/guardian of the above named student, I give consent/permission for WCBVI Health Center staff/wcbvi staff, plane/bus chaperones, or medical/emergency personnel, in the event of sudden illness or injury, to obtain/provide necessary medical or emergency care. Name of Student s Physician: Telephone number: Clinic or Hospital Name (if applicable): Address: City/State/Zip: Signature: Date Student Health History: Visual Acuity: OU: (OD: OS : ) Vision Diagnosis: Date of last visit to physician/or health exam: Recent history of hospitalization, injuries, or illnesses: Any activities student is not able to participate in due to health reasons, please explain: Special dietary requirements or food allergies: Health Form 2 Student s Name: 4 of 10

Illness History: Has your child had any of the following? Anemia Asthma Bed-wetting Chicken Pox Constipation Diarrhea Ear Infections Eczema Heart Problems Hypoglycemia Lead Poisoning Measles Menstrual Problems Mumps Rheumatic Fever Rubella Scarlet Fever Seizures Sickle Cell Skin Disorders Sleep Disorders Tonsillitis Whooping Cough Other: Are there current (or recent) concerns for your child? Health Information: Shunt: Seizure Disorder: Growth Hormone Deficiency: Yes No Yes No Yes No Right Left If Yes, Type: Frequency: If Yes: Hormones Currently Prescribed: Both Sides Date of last seizure: Yes No Functioning: Typical behavior postseizure: Child s tolerance to injections: Yes No Neurosurgeon: Neurologist: Endocrinologist: Telephone: Telephone: Telephone: Address/City/St/Zip: Address/City/St/Zip: Address/City/St/Zip: **Chaperone of student is responsible for all students medication needs. Health Form 3 Student s Name 5 of 10

Allergies: Yes No What type of bodily response/ Is an Epi-Pen Does your child If Yes: /physical reaction does your child have when exposed? prescribed? take allergy shots? Seasonal Dogs/cats Milk/eggs/dairy Peanuts Tree nuts Wheat Fish/shellfish Environmental (dust, smoke, etc.) Other: Yes No Yes No Allergist: Address: City/State/Zip: Telephone: Please list all special considerations, medications, etc. that pertain to your child while on a WCBVI-sponsored field trip/program activity: Any information that will help us in working with your child: ******************************************************************************************** Questions? Call us: For Braille Challenge information: David Hyde, Professional Development Coordinator, WCBVI Outreach 1700 W State Street Janesville WI 53546 608-758-6152 or 866-284-1107 Ext. (3, then 4) Fax: 608-758-6169 david.hyde@wcbvi.k12.wi.us For Braille Olympics information: Diane Karrow, Office Operations Associate 1700 W State Street Janesville WI 53546 608-758-6110 or 800-832-9784 Ext. (3, then 1) Fax 608-758-6116 diane.karrow@wcbvi.k12.wi.us 6 of 10

Completed Registration Form must be received by January 8, 2018 to secure your place in this program! Send registration to: WCBVI Braille Challenge/Braille Olympics 1700 W State Street Janesville, WI 53546 Authorization to participate in the Wisconsin Center for the Blind and Visually Impaired Activities: I hereby give permission for my child to go on WCBVI-sponsored field trips away from the program premises, whether on foot or by vehicle. I give permission for my child to participate in all program activities. I understand s/he is expected to follow the Center s rules and regulations for conduct while on any WCBVI-sponsored program activities. Custodial Parent/Guardian Signature Date Parental Release of Information: For photos/names, to be used in local news stories and our school newsletter. CRIMINAL BACKGROUND CHECK FOR ADULTS 7 of 10

Wisconsin Department of Public Instruction AUTHORIZATION TO RELEASE INFORMATION FOR DEPARTMENT VOLUNTEERS PI-2660-V (New 08-08) INSTRUCTIONS: Please return the completed form to WCBVI Amanda Jordan 1700 W State St Janesville, WI 53546 Fax: 608-758-6161 The Department of Public Instruction conducts criminal background checks as a condition of appointment to volunteer positions. The background check includes a review of any pending charges or convictions. I HEREBY AUTHORIZE the Department of Public Instruction to conduct a criminal background check. In connection with this consent, I authorize the use of law enforcement agencies and/or private background check organizations to assist the department in collecting this information. I hereby authorize and request any present or former employer, school, police department, financial institution or other persons having personal knowledge of me to furnish the Department of Public Instruction or its designated agents with any and all information in their possession regarding me in connection with a requested appointment as a volunteer. I authorize that a photocopy of this authorization be accepted with the same authority as the original. I am aware that any personally identifiable information requested (e.g., gender, date of birth, etc.) is for the sole purpose of accurately gathering the information needed for the criminal background check and will not be used to unlawfully discriminate against me. I also am aware that records of arrests or pending charges and/or convictions are not an absolute bar to appointment as a volunteer. Such information will be used to determine if there is a substantial relationship between the circumstances of the pending charge and/or conviction and the volunteer assignment for which I am being considered. I release the Department of Public Instruction and its agents, officials, representatives or assigned agencies, including officers, employees or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may anytime result to me, my heirs, family, or associates because of compliance with this authorization and request to release. Volunteer Placement / Type of Service WCBVI Braille Challenge/Olympics Full Legal Name GENERAL INFORMATION DPI Location / Office Janesville/WCBVI First Middle Last Volunteer Placement Contact Amanda Jordan Other Names you have Used* Email address Date of Birth Mo./Day/Yr. Gender Current Address, Street City State Zip Male Female Have you lived or studied outside Wisconsin at any time in the past 20 years, after the age of 17? No Yes Where: Telephone Area Code/No. Social Security No.* Have you ever been convicted of a crime or have any pending criminal charges against you? This refers only to felonies and misdemeanors. You do not need to include noncriminal violations or municipal ordinance violations. If unsure whether the charge is criminal or noncriminal, disclose it. No Yes Provide details below. SIGNATURE I HEREBY CERTIFY, to the best of my knowledge, that the information provided herein is true and complete. I understand that any falsification or omission may disqualify me for this volunteer assignment. Signature of Applicant Ø Date Signed Mo./Day/Yr. DETAILS Indicate nature, date(s), court case number, county, and state or as much information as possible, of conviction(s) and/or pending charges. Charge or Conviction Date Court Case Number County & State *This information is needed to verify the accuracy of the information received from law enforcement agencies. 8 of 10

WISCONSIN REGIONAL BRAILLE CHALLENGE Janesville February 15, 2018 Snow Date: March 1 Sponsored by Wisconsin Center for the Blind & Visually Impaired 2018 PERMISSION FORM Must be signed by parental/legal guardian and returned by January 8, 2018 to WCBVI, 1700 West State St, Janesville, WI 53546, Attn: David Hyde or by fax to (608) 758-6116. Only contests submitted with a signed permission form attached will be eligible for the Braille Challenge Finals at Braille Institute. Please print legal name clearly and fill out completely * Required fields * Last Name * First Name * Address Apt. No. * City * State * ZIP * Birthdate *Age *Grade *Telephone * E-mail Alternate phone Adult attending with student o TVI o Parent o Para T-Shirt Size Youth: o X-Small o Small o Medium o Large Adult: o Small o Medium o Large o XL o XXL o XXXL TO BE COMPLETED BY TEACHER OF THE VISUALLY IMPAIRED (Please fill out completely) Name of Teacher of the Visually Impaired Teacher s Email Teacher s Phone Regional Coordinator Name (if applicable) Mark one. Note: all contests are in UEB format only. Student Contest Level: o App o Fresh o Soph o JV o Varsity (NOT Grade in School) Grades 1 2 Grades 3 4 Grades 5 6 Grades 7 9 Grades 10 12 o At Grade Level Or o Below Grade Level (BGL) *(If Apprentice BGL o Contracted or o Uncontracted) *Students who take a contest below their academic grade level in school or who take the uncontracted Apprentice contest are not eligible to attend the Finals. CONTENT RELEASE o I hereby give permission to Wisconsin Center for the Blind & Visually Impaired ( WCBVI ) and Braille Institute of America, Inc. ( BIA ), for my child to participate in The Braille Challenge preliminary contest. I understand that if my child qualifies, he or she is eligible to attend The Braille Challenge final contest in Los Angeles on June 16, 2018. PHOTOGRAPHIC RELEASE o I hereby authorize WCBVI and BIA to photograph, videotape, or otherwise record by visual, audio, electronic or manual means, the visual likeness and/or voice or other sounds created by the above named contestant (collectively Reproductions ). WCBVI and BIA may use or permit to be used the Reproductions in any CD, DVD, exhibition, display, publication, solicitation or promotional or educational material or on any website including without limitation BIA s website, Facebook, or YouTube without compensation to the contestant, the contestant s heirs, successors or assigns. Parent s Print Name Signature 1-800-BRAILLE (272-4553) BrailleChallenge.org Page 1 9 of 10

10 of 10