Student Information

Student First Name:
Student Last Name:

Student Date of Birth:
Print Disabled: Yes No Legally Blind: Yes No

Grade Level: Pre K K 1 2 3 4 5 6 7 8 9 10 11 12
Student School District:
Student Current School Placement:

What type of material are you requesting (select all that apply):
Braille: Yes No Electronic Text: Yes No Large Print: Yes No Audio: Yes No

Is student registered to receive materials from the APH Federal Quota Account?: Yes No (For more information: http://dpi.wi.gov/sped/doc/vifedquota.doc)

Is student registered with Recording for the Blind and Dyslexic (RFB&D) to receive audio books?: Yes No

Is the need for accessible materials documented in this student's IEP?: Yes No

Contact Information for the Teacher of the Visually Impaired

TVI First Name:
TVI Last Name:

TVI E-Maill:

TVI Mailing Address:

TVI Phone: Phone Type: Work Cell Home

Contact Information for the Special Educator

Special Educator First Name:
Special Educator Last Name:

Special Educator E-Mail:

Special Educator Mailing Address:

Special Educator Phone: Phone Type: Work Cell Home

Form Submitted By:
E-Mail address of person submitting this form:

Date Submitted:
IP Submitted From:

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