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Paul V. Sherlock Center on Disabilities

Rhode Island APH Census Registration Form

Please use this form to register one or more students to the Rhode Island APH Census. Refer to the registration packet (link) for specific requirements. To be eligible, individuals must meet the functionality eligibility; be enrolled in your educational programs as of Monday, January 1, 2024; and have a written education plan and parental consent on file at your district/agency.

For questions, please contact Stefanie Davit at sdavit@ric.edu. 
Person completing:
This question requires a valid email address.
Student Information (all questions are required):
This question requires a valid date format of DD/MM/YYYY.
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Individual Placement Code: *This question is required.
Definitions: 

Meet the Definition of Blindness (MDB): a central visual acuity of 20/200 or less (using a Snellen chart or an acuity determined in Snellen equivalents) in the better eye with the best correction or a peripheral field of vision no greater than 20 degrees.

Function at the Definition of Blindness (FDB): when visual function meets the definition of blindness as determined by an eye care specialist (ophthalmologist or optometrist) or other medical doctor such as a neurologist. Students in this category manifest unique visual characteristics often found in conditions referred to as neurological, cortical, or cerebral visual impairment (e.g., brain injury or dysfunction).

If NEITHER are met, students may also be eligible because they: Qualify under the Individuals with Disabilities Education Act (IDEA) definition of blindness: an impairment in vision, that, even with correction, adversely affects a child’s educational performance (34 CFR §300.8(c)(13)).
 
Primary Language Used for Instruction in the Classroom: (check one) *This question is required.
Primary Reading Medium: (check one) *This question is required.
Secondary Reading Medium: (check one) *This question is required.Must be different than Primary Reading Medium.
Parent Permission: *This question is required.Checking yes confirms this is on file at the district/agency. Must check yes to be eligible for registration. 
Written Educational Plan: *This question is required.Checking yes confirms this is on file at the district/agency. Must check yes to be eligible for registration.
Signature: *This question is required.Note: You must provide a signature and type your name in the "signature of" box. 
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Signature of
This question requires a valid date format of MM/DD/YYYY.
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