Apply to the College Success @ Perkins Program

Student



ex: 1/2/2005






*To add additional contacts use the Add Another Contact link below the first contact
*Family Contact




must be unique for each contact

ex: ###-###-####
Educational Information




Daily Living Skills

Social Skills

Behavior and Adjustment

(Please consider aspects such as executive functioning skills, self-regulatory skills, anger management, and sleep disorders)

Communication


Orientation and Mobility

Medical Information

Other Thoughts

College Success Program - Activities & Short Answer Questions (To be completed by the student.)

(Example: Soprano in Chorus at Smith High School. I sing with the chorus twice a week and during monthly concerts. I enjoy folk music and perform occasional solos.)


Other person completing form





ex: ###-###-####

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)
Required Application Materials
Optional Application Materials
Terms and conditions
“I hereby authorize Perkins School for the Blind (“Perkins”) to possess, review, share and release any documents, records or other information provided to Perkins for purposes of considering my application for admission to the College Success Program. Perkins will only share such information with Perkins staff for the purpose of considering my application. The information will otherwise remain confidential and will not be used for any other purpose. The information may be provided to Perkins by me, a TVI/COMS or other individual or organization and may contain personal and medical information. I release Perkins from any and all legal liability that may arise from the disclosure of such records and information.”
I have read and accept the terms and conditions described above (required)