Feel free to reach out to us with any questions or additional materials by email: Admissions@Perkins.org, phone: 617-972-7573 or fax: 617-972-7715. Student First Name (required) Last Name (required) Birthdate (required) ex: 1/2/2005 Gender (required)Please select... Male Female Unspecified Country (required)Please select... United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos ( Keeling ) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d ' Ivoire Croatia ( Hrvatska ) Cuba Cyprus Czech Republic Congo ( DRC ) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands ( Islas Malvinas ) Faroe Islands Fiji Islands Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Samoa San Marino São Tomé and Prìncipe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands ( British ) Virgin Islands Wallis and Futuna Yemen Zambia Zimbabwe Street Address (required) City (required) State (required)Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Zip/Postal Code (required) *To add additional family contacts use the Add Another Family Contact link below the first contact Family Contact Relation to Student (required)Please select... Mother Father Stepmother Stepfather Grandmother Grandfather Great-Grandmother Great-Grandfather Aunt Uncle Family (other) Family Friend Parent Brother Sister First Name (required) Last Name (required) Email (required) must be unique for each contact Phone number (required) ex: ###-###-#### Person completing this form (required)Please select... Family Contact 1 Family Contact 2 School District Contact Other School District/Other Contact District/Organization (required) Title (required) First Name (required) Last Name (required) Email (required) Phone number (required) ex: ###-###-#### Educational Information Current School (required)Please select... Private Public Charter Other (enter below) Other (required) (please describe) Desired Enrollment (required)Please select... Fall 2017 Winter 2017 Spring 2017 Summer 2017 Fall 2018 Winter 2018 Spring 2018 Summer 2018 Fall 2019 Winter 2019 Spring 2019 Summer 2019 Fall 2020 Winter 2020 Spring 2020 Summer 2020 Approximate grade level of educational performance (required) Please describe the student’s strengths: (required): Please describe the student’s weaknesses: (required): Daily Living Skills Daily living skills (including eating, dressing, toileting), and use of adaptive equipment (required): Social Skills Social skills, relationships, and use of leisure time (required): Behavior and Adjustment Are there any behavior and adjustment concerns? (required) Describe any mental health concerns we should be aware of (required): Communication In a few sentences please describe the student’s receptive and expressive language skills (required): What is the student's visual diagnosis? (required) Orientation and Mobility Describe your student’s mobility at school, home, and in the community. Include the use of mobility aids (required): Medical Information Please list your student’s diagnosis, beginning with their visual diagnosis (required): Other Thoughts Is there anything else we should know? (required) File Upload Individual Education Plan (IEP) Current Vision Report Most recent evaluation reports Current audiological report (if applicable) Submit application materials here or by mail, email, or fax. File types that can be uploaded: .doc (Older Microsoft Word format) .docx (Current Microsoft Word format) .pdf (Adobe PDF) .odt (Open Office word processor document) If you have applied to Perkins within the last 6 months, please contact our office before submitting any documents other than this application.