SEE Program Application

Remember to send references to: Olmsted Center for Sight, Attn: SEE Program, 1170 Main Street, Buffalo, NY 14209.

Please complete the information requested below.

Application is being submitted by:
Name:
Phone:
	Please enter phone as ###-###-####
I. Personal Information
Name:
Address:

City:
State, Zip Code:

Email:
Phone:
	Please enter phone as ###-###-####
Cell:
	Please enter cell as ###-###-####

Date of Birth:
	Please enter date of birth as MM/DD/YY

Emergency Contact Information
Name:
Address:

City:
State, Zip Code:
Daytime Phone:
	Please enter phone as ###-###-####
Evening Phone:
	Please enter phone as ###-###-####

Relation to Applicant:

How did you hear about this program?

Please state your disabilities:

Please list any medical conditions we should know about:

If you are visually impaired, please state the cause:

If you are visually impaired, please indicate which of the following you prefer to read:
	Regular Print Large Print Braille

What do you use for mobility?
	White Cane Guide Dog Wheel Chair Travel Independently None

Please list the names and phone numbers of the rehabilitation professionals you are currently working with (for example: Special Ed teacher, TVI, Rehab Counselor, Caseworker, etc.):
Name/Title:
Phone:
	Please enter phone as ###-###-####
Name/Title:
Phone:
	Please enter phone as ###-###-####
Name/Title:
Phone:
	Please enter phone as ###-###-####

II. Education and Employment Experience

High School Name:
High School Address:
Phone:
	Please enter phone as ###-###-####

Current Status at time of application:	HS Freshman HS Sophomore HS Junior HS Senior HS Graduate

Do you plan on continuing your education after high school?
	Yes No

Have you decided on a career path?
	Yes No
If yes, what?

Are you familiar with basic computer applications?
	Yes No

Please list the computer programs you are able to use (for example: Microsoft Word, Internet Explorer, etc.):

Do you require adaptive software? (for example: JAWS, Zoom Text)
	Yes No

Do you have a computer at home?
	Yes No

How often do you work with a computer?
	Only when I have to for school A few times a month A few times a week Every day

Do you have any previous work experience?
	Yes No
If yes, what did you do?
Did you enjoy it?
	Yes No

Please list 3-5 'ideal' summer work experience for yourself.

Please answer the following questions so we can become familiar with your interests

What high school classes interest you the most?

Tell us about your interests. What would you like to be doing in the future?

Tell us why you are interested in the Summer Employment Experience:

Please send two letters of recommendation with your application. Letters of recommendation may be written by any of your teachers or a guidance counselor.

SEE Program Application

Application is being submitted by:

I. Personal Information

Emergency Contact Information

II. Education and Employment Experience

Please answer the following questions so we can become familiar with your interests