Name:

Current address:

Daytime phone number:

Please list the number of adults in your household:

Please list the number of children in your household:

Please list the children in the home w/ visual impairment along with ages:

How does the child travel?

Use of long cane
Sighted guide
Trailing
Wheelchair
Adaptive cane
Other:

Please list any difficulties child is encountering:

• Braille (i.e. writing/ reading/ more instruction / more practice)

• Independent living skills (i.e. making bed/ practicing good hygiene/ etc)

• Mobility (i.e. only uses cane once a week/ cane doesn’t cover body as the child walks/ child refuses to use cane)

Please list previous/current programs child has attended outside of CLB?

How long was the program (s)?

Please list CLB activities/programs previously involved in?

Was the program worthwhile for you?

Please list any changes that you would make in the program?

Please list your favorite activities with CLB or other organizations.

What made this program your favorite?

What programs would you like to see more of (children’s events/activities, parent support groups, family oriented programs, after school programs)?

Please list any additional comments and suggestions.