APPLICATION TO THE COMMISSIONER OF EDUCATION FOR APPROVAL FOR AN EVALUATION TO ATTEND A STATE-OPERATED SCHOOL PHC-10 - Word 
(109 KB)
Updated January 2008
State-Operated School (indicate which school you are applying to):
New York State School for the Blind (NYSSB)
1
New York State School for the Deaf (NYSSD)
1
INSTRUCTIONS
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Please PRINT or TYPE the
information on this application.
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Submit the following medical documentation
with this application:
For a child who is Blind (a
minimum of one of the following documents must be submitted)
- Current ophthalmologic examination
(administered within the last 12 months)
- New York State Commission for the Blind and Visually Handicapped (CBVH)
report indicating legal blindness
For a child who is Deaf:
- Current audiogram (administered within the last 12 months)
-
Send a completed application and required
documentation to the attention of:
Regional Associate
EMSC - SEQA
Nondistrict Unit
One Commerce Plaza, Room 1623
Albany, NY 12234
(518) 473-1185
Attn: PHC-10 Application
NOTE:
During the processing of this application it is necessary that your child
remain in his or her current placement to ensure the continuity of his/her
educational program.
For further assistance in
completing this application please contact the appropriate Office listed
above.
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Date of Application: ____________ |
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Child'sName: _____________________________________
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- Date of Birth:
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(Last)
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- Gender 1F
1M
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- Parent(s)/Guardian(s)
Name(s):
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- Address:
; (City)
(State)
(Zip
Code)
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County of Location:
Telephone
Number: ( ) Email
Address: ______________________
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- Indicate the dominant language used in the home:
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- Indicate child's primary
disability (check only one):
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Blind..........................................................
1
Legally
Blind .............................................
1
Deaf/Blind
............................................. .
1 |
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Deaf.....................................
1
Functionally
Deaf..........................................
1
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- If
child has multiple disabilities (check all that apply)
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Autistic ...................................................
1 |
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Orthopedically Impaired ........................................
1 |
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Emotionally
Disturbed ...........................1 |
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Other Health
Impaired ............................................
1 |
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Hearing
Impaired
....................................1 |
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Speech Impaired.......................................................
1
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Learning Disabled...................................
1 |
Traumatic Brain Injury
.............................................1 |
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Mentally
Retarded........................... ........1 |
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Visually
Impaired .....................................................
1 |
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- Local School District
of Residence:
________________________________________
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Address:
____________________________________________________________________
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(Street)
(City)
(State) (Zip
Code)
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Telephone
Number: (
) Fax:
( )
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- Indicate current
educational placement of child.
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School
Name:
Phone: ( )
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Program Administrator:
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Address:
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(Street)
(City)
(State)
(Zip Code)
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Person completing this application (If different than Parent or Guardian):
Name:
Title/Agency:
Address:
______________________________________________
Telephone
Number:
Email address: __________________
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______________________________________________________________________________
Signature of Parent or Guardian
Date
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