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student registration form 2012


									                                            REGISTRATION FORM

Student will participate in: (mark one)        Braille games__________            Low vision games__________

Student’s Name:                                   Age_________      Grade:        ____    Male_____ Female_______
Parent Name(s):                                                     Parent Phone:
Parent address:
                        Street address                                                   City/State/Zip
School district and school:

Email address for parent:______________________________________________________________________________

Email address for Teacher of the Visually Impaired or other contact teacher:   __________________________________

Name(s) of adults accompanying student to Carnival and relationship to student:

Are there any religious/physical restrictions and/or medical conditions we should be aware of? (Seizures,
diabetes, allergies, special diet, sunburns easily, etc.) Please explain:

                               PERMISSION FOR PHOTO/VIDEO RELEASE

I, as parent/guardian of
give my permission for pictures/videos taken of me and/or my child during the Braille Carnival to be used for
educational purposes in newsletters, workshops, and programs for both professionals and other parents.

Date                                       Signature
                  Please Return This Registration and Permission Form by October 7, 2011
                                             John Roberts
                                               Kentucky School for the Blind
                                        1867 Frankfort Avenue, Louisville, KY 40206
                                      Student Information for Carnival

Student Name:

Eye Condition _______________________________ Visual Acuity __________________

Low Vision Student Information:
My child/student uses the following:
  Large Print       Regular Print                            Monocular              Magnifier             CCTV
Please be sure to bring the monocular and/or magnifier your student uses.

Braille Student Information:
Student’s Braille skills (mark one):
          Tactual readiness
          Beginning Braille reader
_____     Intermediate Braille reader
          Independent Braille reader

Please briefly describe child/student’s Braille skills:____________

Your student will receive a print/braille book at the end of the Carnival. Please choose
3 titles from the list below that your student would enjoy.

3. ______________________________

How many KSB Lunch tickets ($3.00) will your group need? _________

SEND TO: John Roberts, Kentucky School for the Blind, 1867 Frankfort Avenue, Louisville, KY
40206, fax #502-897-2850, or e-mail to John.

The Kentucky School for the Blind does not discriminate on the basis of race, color, national origin, age, religion, marital status, sex, or
handicap in employment, educational programs or activities as set forth in Title IX, Title VI, and Section 504.

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                                 Booklist Prize Options

Please choose 3 titles your student would enjoy receiving. If your student already has
these or you don’t find one he/she would be interested in please contact us for other
options. or

Print/braille options from APH catalog
Capital! Washington D.C. from A-Z by Laura Krauss Melmed
Curious George (The Original) by H.A. Rey
Dear Santa Please Come to the 19th Floor by Yin
Going Someplace Special by Patricia McKissack
Looking Out for Sarah by Glenna Lang
The Mysterious Tadpole by Steven Kellogg
Oranges On Golden Mountain by Elizabeth Partridge
Pumpkin Eye by Denise Fleming
Sylvester and the Magic Pebble by William Steig
Where the Wild Things Are by Maurice Sendak

Print only options
The Magic School Bus #6 The Giant Germ
The Magic School Bus #14 Electric Storm
Holes by Louis Sachar
The Twits by Roald Dahl
The Landry News by Andrew Clements
Frindle by Andrew Clements
Mouse Tales by Arnold Lobel
Disney’s Fairies: Lily’s Pesky Plant by Kristen Larsen

Braille only options
Cloudy with a Chance of Meatballs by Judi Barrett
Little House in the Big Woods by Laura Ingalls Wilder
Sees Behind Trees by Michael Dorris
From Anna by Jean Little
The Seeing Summer by Jeannette Eyerly
Henry and Mudge and the Happy Cat by Cynthia Rylant
Dinosaurs Are 568 by Jean Rogers
Meet Molly , An American Girl by Valerie Tripp
Nate the Great and the Big Sniff by Marjorie Weinman Sharmat and Mitchell Sharmat
Henry and Mudge and the Bedtime Thumps by Cynthia Rylant
Flight to Freedom by Anna Veciana-Suarez (grade 5)
Gus and Grandpa Go Fishing by Claudia Mills (grades K-3)

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