Buddy Program - Application

This summer, the Louisiana Center for the Blind will sponsor one session of the “Buddy” Program from July 15 - August 4.

 

Perhaps we will have the opportunity to work with your child this summer. We know it will be a memorable experience for both you and them. If you are interested, please complete this application by April 8th or call Eric Guillory at 800-234-4166.

 

Due to limited space, we cannot guarantee that every applicant will be granted enrollment.

 

Please note that the fee for students not from Louisiana attending the program is $1,000-which is all-inclusive save for transportation to and from the program.

Child's Name:

Parent's Name:

Mailing Address:

City:

State:

Zip Code:

Email Address:

Telephone Number:

Child's Age:

School:

Current Grade Level: (for 2011-2012 school year):

V.I. Teacher:

Does your child use large print or magnification devices?:

   yes

   no

Does your child use a cane?:

   yes

   no

Does your child know braille?:

   yes

   no

Contracted or Uncontracted:

   contracted

   uncontracted

Cause of blindness:

Visual acuity:

Does your child have any other disabilities or medical conditions?:

Hobbies: