Student Information

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* 1. Student Name

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* 2. Student Age

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* 3. Student Grade

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* 4. Student Gender

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* 5. Student Vision Diagnosis

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* 6. Student Visual Acuity

Program Selections - If your student is interested in attending more than one session, we will make every effort to accommodate them on a first come, first serve basis. However, our space is limited this year so please indicate a first and second choice if we just cannot accommodate your student for both weeks.

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* 7. Choose which Summer Exploration Session program(s) your student is interested in attending

Custodial Parent/Guardian Contact Information

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* 8. Custodial Parent/Guardian Name

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* 9. Custodial Parent/Guardian Home Address

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* 10. Custodial Parent/Guardian Phone

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* 12. Please provide any other information about the Custodial Parent/Guardian you feel is applicable (relationship to student, additional phone number, etc.)

Non-Custodial Parent/Guardian Contact Information

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* 13. Non-Custodial Parent/Guardian Name

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* 14. Non-Custodial Parent/Guardian Home Address

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* 15. Non-Custodial Parent/Guardian Phone

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* 17. Please provide any other information about the Non-Custodial Parent/Guardian you feel is applicable (relationship to student, additional phone number, etc.)

Emergency Contact Information

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* 18. Emergency Contact First and Last Name

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* 19. Emergency Contact Home Address

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* 20. Emergency Contact Phone

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* 22. Please provide any other information about the Emergency Contact person you feel is applicable (relationship to student, additional phone number, etc.)

School Information

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* 23. School District

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* 24. School currently attending

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* 25. School Address

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* 26. School Contact Person

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* 27. School/Contact Person Phone

Educational/Instruction Overview

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* 29. Is your student mainstreamed?

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* 30. Reading/Learning Media:

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* 31. Does your student have an assistant?

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* 32. If you answered yes to the previous question, for what purpose?

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* 33. What Assistive Technology Devices does your student regularly use?

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* 34. List any additional disabilities

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* 35. List any special dietary needs

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* 36. List any special transportation needs

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* 37. List any behaviors we should be aware of

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* 38. List typical Leisure Activities

Residential Housing and Transportation
NOTE: All students leave at 1:00 p.m. on Fridays during Summer Programs and return home every weekend.

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* 39. Residential Housing – The MSB residential program provides housing for students who are Missouri residents that are unable to be transported to and from school on a daily basis. All dormitories are staffed with residential advisors who provide assistance to each student based on individual needs. Will your child be a Residential student during their Summer Exploration Program(s)?

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* 40. Transportation – In most cases, MSB can provide students with transportation to and from their homes on a daily basis for local students and a weekly basis for Residential students. Please indicate how often your child will need transportation from MSB to and from their homes:

Permissions

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* 41. General Events – Permission is granted for my child to attend field trips and activities of which the school approves. I release MSB from responsibility connected with illness, accidents, damages or bodily injury incurred during the trip. EXAMPLE: Educational, Recreational and Athletic events.

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* 42. Internet/Computer Usage – As the parent or guardian of this student, I have read MSB’s Technology Usage Policy. I understand that access is designed for educational purposes. I also understand that MSB is employing monitoring procedures and software to access the Internet. However, I recognize that it is impossible for MSB to restrict access to all controversial materials and I will not hold them responsible for materials acquired on the network. I hereby give permission to provide independent access to the Internet.

Photo/Video/News Print/Television/Radio – I hereby give MSB and its employees, representatives, contractors and media or other organizations approved by MSB permission to print, photograph, and record my child for use in audio, video, film, or any other electronic, digital or printed media (to further be known as image and/or likeness) that may be published and available inside or outside of MSB.

1. This is with the understanding that neither MSB nor its representatives will reproduce said photograph, interview, or likeness for any commercial value or receive monetary gain for use of any reproduction/broadcast of said photograph or likeness. I am also fully aware that I will not receive monetary compensation for my child’s participation.

2. I further release and relieve MSB and other representatives from any liabilities, known or unknown, arising out of the use of this material.

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* 43. Public News Media

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* 44. Public Print Media

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* 45. Informational Print Material

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* 46. Informational MSB Presentations

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* 47. MSB Website (videos, pictures, articles)

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* 48. Social Media (Facebook, Twitter, Instagram and YouTube) – I hereby give MSB permission to feature my child in social media posts in the following capacity (please check only one option):

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* 49. I understand that the permissions and authorizations granted on this form will remain in effect as long as my child continues to be enrolled at MSB. I also understand that I can change any permission or authorization at any time by writing to the Assistant Superintendent.

Documents and Forms
Please upload your student's most recent IEP and completed MSB Health Center forms below.
Alternatively, you may submit these documents in one of the following ways:
  • Email to Desiree.Morris@msb.dese.mo.gov
  • Fax to 314-776-1875
  • Mail to MSB:
Missouri School for the Blind
Attention: Summer Programs
3815 Magnolia Avenue
St. Louis, MO 63110

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* 50. Upload your student's current IEP

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* 51. Upload the MSB Health Center forms, which can be downloaded here: 2026 MSB Health Center Forms

If you have further questions or need additional information, please contact: Desiree.Morris@msb.dese.mo.gov

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