APPLICATION TO THE COMMISSIONER OF EDUCATION FOR APPROVAL FOR AN EVALUATION TO ATTEND A STATE-OPERATED SCHOOL PHC-10 - Word Word Document (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

 

  1. Please PRINT or TYPE the information on this application.
     

  2. 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)

For a child who is Deaf:

  1. Submit the following school/educational information with this application (if available):
  1. 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.

 

 

  Date of Application: ____________
  1. Child'sName: _____________________________________

  1. Date of Birth:

(Last)

  1. Gender 1F 1M
    
  1. Parent(s)/Guardian(s) Name(s):   

 

  1. Address: ;        (City)      (State)                 (Zip Code)
 County of Location:

Telephone Number: (      ) Email Address: ______________________

  1. Indicate the dominant language used in the home:   
  1. Indicate child's primary disability (check only one):

Blind.......................................................... 1

Legally Blind ............................................. 1

Deaf/Blind ............................................. . 1

Deaf..................................... 1

Functionally Deaf.......................................... 1

 

  1. If child has multiple disabilities (check all that apply)

Autistic ................................................... 1

Orthopedically Impaired ........................................ 1

Emotionally Disturbed ...........................1

Other Health Impaired ............................................ 1

Hearing Impaired ....................................1

Speech Impaired....................................................... 1

Learning Disabled................................... 1 Traumatic Brain Injury .............................................1

Mentally Retarded........................... ........1

Visually Impaired ..................................................... 1

  1. Local School District of Residence:  ________________________________________

Address:  ____________________________________________________________________                              

                       (Street)                                                                                     (City)                     (State)                   (Zip Code)

 

 Telephone Number: (      )                                               Fax: (      )

  1. Indicate current educational placement of child.

School Name:                                                                                 Phone: (      )                                  

Program Administrator:                                                                                                                                             

Address:                                                                                                                                                                       

  (Street)                                                (City)                          (State)                            (Zip Code)

 
  1. Person completing this application (If different than Parent or Guardian):

Name:                                                                                                        

Title/Agency:                                                                                              

Address: ______________________________________________

Telephone Number:                                                                 Email address: __________________

 
  1. ______________________________________________________________________________
    Signature of Parent or Guardian                                                          Date

 

SED Use Only:

 

  Initials

1Received - Date:______________________________

____________

   
1Approved (Regional Associate) - Date: ________________ ____________

SED Action:

1Send Attachment D: Referral

1Original to : Parent

1Copy to: CSE Chairperson

1Copy to: State-operated School

Date: __________________________________

 
   
1Not Approved (Regional Associate) - Date: ________________ ____________

SED Action:

1Send Attachment G or G-1: Rejection

1Original to : Parent

1Copy to: CSE Chairperson

1Copy to: State-operated School

Date: __________________________________