APPLICATION FOR ENROLLMENT I would like to enroll in the following program: Adult Continuing Education Program (ACE) (If you are age 14 or older and have a visual impairment) Fill out print pages 2, 3, 4, 5, 6, 11, 12. High School Program (HS) (If you are age 14 or older, visually impaired and wish to earn high school credits) Fill out print pages 2, 3, 4, 5, 6, 11, 12. Family Education Program (FE) (If you are an immediate family member of someone with a visual impairment) Fill out pages 2, 3, 4, 7, 8, 9. Professional Education Program (PE) (If you provide direct service to a visually impaired person in the course of your paid or volunteer duties) Fill out pages 2, 3, 4, 9. To Enroll Online, Go To: www.hadley.edu Hadley Contact Information The Hadley School for the Blind 700 Elm Street Winnetka, IL 60093-2554 Telephone (847) 446-8111 TTY (847) 441-8111 Student Services Toll-Free (800) 526-9909 Fax (847) 446-0855 Student Services email: student_services@hadley.edu Hadley Website: www.hadley.edu 2 GENERAL INFORMATION: ALL APPLICANTS Prefix: Mr. Mrs. Ms. Other ---- First Name: ---- Middle Initial: ---- Last Name: ---- Sex: M or F If previously enrolled under a different last name, please indicate the name: -- Mailing Information Street Address: ---- City or Town: ---- State/Province: ---- Zip/Postal Code: ---- Country: ---- Telephone Numbers: Home: ---- Work: ---- Cell: ---- Email: ---- Date of Birth (mm/dd/yy): ---- How did you first hear about Hadley? (Indicate One) Agency School Publication Friend/family Hadley student/staff Conference Library Correctional Facility Internet Site Radio/TV Other (Specify): ---- List specific name of information source: ---- 3 Indicate your highest level of education: Elementary School Middle School High School (no diploma) High School Diploma GED Associates Bachelors Masters Ph.D. Other ---- Place of Birth: ---- Is English your native language? Yes or No If not, do you speak it and understand it well? Yes or No Do you read: Uncontracted Braille (Grade 1)? Yes or No Contracted Braille (Grade 2)? Yes or No Nemeth Code (for mathematics)? Yes or No Please indicate which of the following you have access to: Cassette player/recorder: 2-track or 4-track Cassette player only: 2-track or 4-track Personal Computer Braillewriter Slate/Stylus Typewriter CD Player Other ---- How would you like to receive the Hadley Student Newsletter? (Indicate one): Braille Cassette Large Print Email Ethnic Background: Optional (for statistical information only) African-American Caucasian Hispanic Asian Native American Other ---- 4 COURSE INFORMATION: ALL APPLICANTS Before completing this section, review the Hadley Course Catalog for course titles and media. Use the following letter(s) to indicate the medium you prefer: B (braille) C (audiocassette) LP (large print) P (print) DL (download) OL (online) Students are enrolled in one course at at time. List your course preferences in order: 1 course number; course title; media 2 course number; course title; media Please write a brief statement (30 words or less) about your goal as a Hadley student. Agreement: I understand that when I enroll in a course that I am making a commitment of my time. I have read and understand the school's policies regarding lesson preparation and submission. Failure to start or remain active in my course may result in cancellation. Failure to complete multiple courses may result in suspension. Finally, I will respect the copyright of my Hadley materials and understand they are not for resale. Signature ---- Date ---- 5 TO CONTINUE Adult Continuing Education and High School Applicants proceed page 5. Family Education Applicants proceed to page 7. Professional Education Applicants proceed to page 9. Adult Continuing Education and High School Program Applicants Only Students in these programs must complete the Entrance Assignment before enrollment in their first course. How would you prefer to receive the entrance assignment? (Indicate one): braille large print cassette online For other communications--how do you want the Hadley staff to correspond with you? (Indicate one): braille large print cassette email Are you receiving rehabilitation services? Yes or No If yes, provide the following information: Agency name: ---- Street address: ---- City, state and zip code: ---- Phone number: ---- Contact name: ---- 6 For High School Students Only (U.S. Residents) I am interested in receiving (indicate one): Credit to transfer to my local high school or Hadley diploma--Note: If you are applying for a Hadley diploma and you have earned previous high school credit, please arrange for your transcript to be sent to Student Services. List the name of the schools attended: ---- U.S. Residents Only An eye report signed by an eye specialist or medical doctor is required in order to process your enrollment. Make arrangements for an eye report to be sent if you do not have a report on file. An Eye Report Form is provided at the end of the print application for your convenience. Your application will be DISCARDED three months after the date of submission if no eye report is received. What is your eye condition? ---- Age at onset of eye condition: ---- Specify your visual acuity (e.g., 20/70, 20/200, NLP) Left eye (OS) ---- Right eye (OD) ---- Are you hearing impaired? Yes or No Do you have a disability (other than vision and hearing) that would affect your ability to prepare assignments? Yes or No If yes, list the disability: ---- 7 FAMILY EDUCATION PROGRAM APPLICANTS ONLY Family Member Information--Provide the information requested about your visually impaired family member. How are you related? ---- Name of blind/visually impaired individual: ---- Sex: M or F Date of birth: ---- Eye condition: ---- Age at onset of eye condition: ---- If known, please specify visual acuity (e.g., 20/70, 20/200, NLP): Left eye (OS) ---- Right eye (OD) ---- Is the individual hearing impaired? Yes or No If yes, specify the degree of loss: mild; moderate; severe Is there a disability other than vision or hearing loss? Yes or No If yes, list the disability: ---- Does the individual live with you? Yes or No Are any other members of the immediate family blind or visually impaired? Yes or No 8 Family Member Under Age 14 Complete this section if you are the parent or grandparent of a blind or visually impaired child under the age of 14. List the agencies that provide educational placement and vision services the child is currently receiving: ---- List all of the child's brothers and sisters living with him/her: Name ---- Date of Birth ---- Family Member Age 14 and Older Complete this section if you are a family member of a blind or visually impaired individual 14 years of age or older. Are you or your family member receiving services related to the individual's blindness? Yes or No If yes, please describe: ---- 9 Is the family member a Hadley student? Yes or No If not, would you like us to send you a Hadley Course Catalog and enrollment application for the blind adult? Yes or No If so, what medium would you prefer: braille; cassette; large print; CD- ROM; I'll order a Hadley Course Catalog online at: www.hadley.edu PROFESSIONAL EDUCATION PROGRAM APPLICANTS ONLY Do you work directly with blind or visually impaired individual(s)? Yes or No Are you a: paid employee or volunteer? Employer/Agency: ---- Street address: ---- City, state and zip code: ---- Job title: ---- Phone number: ---- Work email address: ---- Which age range best describes the individuals you work with: 0-5 6-12 13-18 Adults Senior Adults Do any of the individuals you work with take Hadley courses? Yes or No 10 EYE REPORT for The Hadley School for the Blind Prior to enrollment, Adult Continuing Education and High School students in the United States must complete and submit this Eye Report Form to Student Services. 11 To the U.S. student applicant: Please mail or take this form to your physician or eye specialist. To the physician or eye specialist: Please indicate patient's visual acuity and/or peripheral field and answer all of the questions that follow: VISUAL ACUITY (best corrected, for distance) Left Eye OS Visual Field ---- degrees Right Eye OD Visual Field ---- degrees Light perception: left eye; right eye Object perception: left eye; right eye Hand movements: left eye; right eye Counts fingers: left eye; right eye at distance: left eye ----; right eye ---- Name, address and phone number of physician or eye specialist: ---- Patient's name: ---- Address: ---- City/State/Zip: ---- Does this patient meet the standard definition of legal blindness? Yes or No Condition is considered to be: Progressive Stable Capable of improvement Uncertain Diagnosis (each eye): ---- Signature_/Date: ---- Return promptly to: The Hadley School for the Blind Student Services Department 700 Elm Street Winnetka, IL 60093-2554 Telephone (800) 526-9909 Fax (847) 446-0855