Please Select One LEGO Robotics Camp Internship Job Shadowing Reason for Filing: E-Mail: Parent/Guardian Cell# School Name: Race: Schooling: Please Select One American Indian Asian or Pacific Islander Black, not of Hispanic origin Hispanic White, not of Hispanic origin Please Select One 5th grade 6th grade 7th grade 8th grade Sophomores Freshman Juniors Seniors Post-High School Out of school Please note any additional information or concerns related to the applicant. (For example; my child needs large font, or she/he needs a sign language interpreter) Notes: Do you use a wheelchair? Parent/Guardian Work# Parent/Guardian Home#: Parent/Guardian Name: Home Phone # ZipCode: State: City: Address Line 2: Address Line 1: Please Select One Male Female Referrer's Name: Please Select One Brochure Health Care Professional Meeting Other OVR Parent Self-Referral Special Ed Specialist Teacher - 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 1 - Jan 2 - Feb 3 - Mar 4 - Apr 5 - May 6 - Jun 7 - Jul 8 - Aug 9 - Sep 10 - Oct 11 - Nov 12 - Dec Day: Year: Month: First Name: Last Name: Date of Birth: Gender: Referred By: Please Select One Attention Deficit Hyperactivity Disorder (ADHD) Autism Deaf-Blindness Hearing Impairments (including deafness) Mental Retardation Multiple Disabilities Not Applicable Orthopedic Impairments Other Health Impairments Serious Emotional Disturbance Specific Learning Disabilities Speech or Language Impairments Traumatic Brain Injury Visual Impairments (including blindness) Disability:

YES

NO