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Wisconsin Braille Inc.

Braille Mentor Program

Student Referral Form

 

 

 

Directions:If you wish to complete this form, you may do so by copying the entire document and pasting it into an empty MS Word or Text document.You can also print it out in order to complete the form.Once completed, mail the form either electronically or via US mail to the project coordinators.

 

Contact Information for Person Making Referral

 

Name:††††††† _______________________________________

Address:†††† _______________________________________

††††††††††††††††† _______________________________________

Phone:††††††† _______________________________________

Email:†††††††† _______________________________________

Relationship to student:

£Parent†††††† £Teacher†††††† £Other ________________

 

Student Information

 

Name:††††††† _______________________________________

Age:†††††††††† _______________________________________

Grade:††††††† _______________________________________

School:†††††† _______________________________________

Address:†††† _______________________________________

††††††††††††††††† _______________________________________

Describe the studentís Braille reading level:††††††† _________________________________

_____________________________________________________________________

Interests:†††† ____________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Needs/Preferences:______________________________________________________

_____________________________________________________________________

_____________________________________________________________________

 

Parent Signature: _______________________________ Date: __________________

 

 

 

 

Mail form to:

 

Cheryl Orgas, 4222 N. Maryland Ave., Shorewood, WI53211

meekerorgas@ameritech.net

or

Judy Turner, 402 W. Carroll St., Portage, WI 53901

jeturner@madison.k12.wi.us