Perkins Short Course Application

For more information contact Short Courses coordinator Patrick Ryan at patrick.ryan@perkins.org 617-972-7812.

Full payment or written authorization from your funding source must be received at least 2 weeks in advance of a program


Programs (required)
Student




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

ex: 1/2/2005







*Family Contact




must be unique for each contact

ex: ###-###-####
*To add additional contacts use the Add Another Contact link below the first contact
**Professional Contact




must be unique for each contact

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


ex. Vocational Rehabilitation Counselor, TVI, Transition Specialist
* "Relation to Student" is how the individual relates to the student, not their individual title. Examples: Title of TVI [Teacher of the Visually Impaired] would have a Relationship to Student of "Teacher", Relationship of "State Counselor" might have Title of Vocational Rehabilitation Counselor, Transition Specialist, etc.

At minimum, please add the student’s vision teacher and state counselor, additional contacts will help us to better serve the needs of the program participant.


Educational Information



(ex. Bedford, MA)

Behavior and Adjustment




It is the responsibility of the family to secure funding for the summer program. Please select all funding sources you will be pursuing: (required)

Other Thoughts

File Upload (if there are documents that need to be submitted, you may attach them here)


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)