Adm pkt 07-ss sec i.doc

HELEN KELLER NATIONAL CENTER
141 MIDDLE NECK ROAD
SANDS POINT, NEW YORK 11050-1299
(516) 944-8900 V, (516) 944-8637 TTY, (516) 944-7302 FAX
TWO WEEK SUMMER SEMINAR ADMISSIONS PACKET
THE FOLLOWING INFORMATION IS REQUIRED OF ALL APPLICANTS
FOR ADMISSION TO THE HKNC SEMINAR PROGRAM
SECTION I:
ADMISSIONS PACKET PAGES 1 – 10

SECTION II:
SPONSORING AGENCY AGREEMENT PAGES 1-2
SECTION III:
MEDICAL INFORMATION

Current Physical Exam Pages 1- 2
Psychotropic Medication Evaluation and Assessment Pages 3 - 5
LDSS-3122 Medical Evaluation Form completed with 30 days prior to admission.
(Yellow Form)
Psychiatric/MD Summary for anyone using Psychotropic or Anticonvulsant
THE FOLLOWING REPORTS ARE ALSO REQUESTED:
AUDIOLOGICAL
OPHTHALMOLOGICAL
IEP OR Current Educational Reports

PLEASE BE AWARE THAT ADDITIONAL REPORTS MAY BE REQUIRED.
Following review by the Admissions Committee, additional medical or mental health information
may be requested. HKNC is not a medical facility, therefore, it is important to target and resolve
any medical problems prior to entry.
Rev: 03/22/07
HELEN KELLER NATIONAL CENTER
TWO WEEK SUMMER SEMINAR ADMISSIONS PACKET
SECTION I
PERSONAL INFORMATION
APPLICANT’S NAME:
PLEASE PROVIDE A CURRENT PHOTOGRAPH FOR IDENTIFICATION PURPOSES
HELEN KELLER NATIONAL CENTER
FOR DEAF-BLIND YOUTHS AND ADULTS
TWO WEEK SUMMER SEMINAR
PERSONAL INFORMATION
CURRENT ADDRESS:
TELEPHONE NO:
PERMANENT
HOME ADDRESS:
TELEPHONE NO:
SOCIAL SECURITY NO:

DATE OF BIRTH:

PLACE OF BIRTH:
MARITAL STATUS: (Single, Married, Separated, Widow, Divorced)
CITIZENSHIP STATUS:
HAS A LEGAL GUARDIAN OR
If Yes, please enter name and address of MEDICAL POWER OF ATTORNEY
BEEN NAMED BY THE COURT:
(PLEASE PROVIDE A COPY OF COURT PAPERWORK) Address:
PERSON TO NOTIFY IN CASE OF EMERGENCY: (Not
BUSINESS TELEPHONE:

HOME TELEPHONE:

RELATIONSHIP TO APPLICANT:
PERSONAL HISTORY
A. Family History and/or Key People in Applicant’s Life:
Relationship to
Occupation
Date of Birth
In/Out Home
Applicant
B. Educational History:
School Attended Grade Completed/Date
Diploma/Certificate/Degree
Type of Program
If you did not complete an educational program, why? C. Income:
Income currently received directly by applicant or by others on applicant’s behalf:
Source of Income
Amount Per Month
Employment:
Social Security
Type: SSDI SSI Other

Under parent or own Social Security Number?
Parent Own
Is applicant registered with Social Services as
Yes No Not sure
deaf-blind?

Is applicant his/her own payee
If not, who is?
Relationship
Address:
Telephone No.:
• Applicant should maintain a small account at HKNC for personal expenses. Applicant and/or family (payee) should plan on having an agreed upon amount of money to be maintained in and by our accounting department. VISION AND HEARING
Cause of vision loss:
Age of onset of visual difficulties:
Type of onset:
Sudden Gradual
Use of residual vision with and/or without
correction (please describe):

Are optical aids being used presently or have
they been used in the past?
If yes, please list devices.
Has medical and/or surgical treatment ever
been done or recommended? (please explain):

Cause of hearing loss:

Age of onset of hearing difficulties:

Type of Onset:
Sudden Gradual
Use of residual hearing with and/or without
hearing aid and/or cochlear implant.
(please describe)
Are hearing aids or cochlear implants being
used presently? Have they been used in the
past? (please comment)
Has medical and/or surgical treatment ever
been done or recommended? (please explain)

Deaf-Blind Registry
Is applicant in the HKNC National Registry?
Yes No Not sure
COMMUNICATION SKILLS
Does the applicant use any of the following methods of communication? Circle responses. Communication Methods
Skill Level/Comments
American Sign Language
Skilled Developing Skill No Skill Visual Tactual/Contact signing Sign Language presented in English word
Describe any accommodations needed for the
applicant to receive sign visually. (distance,
avoid glare, lighting, clothing in contrast to
skin tone)

Does the applicant use a language other than
English or American Sign Language? (i.e.,
Native American Sign Language, Spanish)

Does the applicant have a name sign? Please
describe.
Manual Alphabet (fingerspelling)
Speech – Does the applicant use speech as
his/her primary method of expressive
communication?

Would the applicant’s speech be clearly
understood by someone unfamiliar with him or
her?

Speech – Does the applicant use survival
speech phrases (ex. “How are you?”, “Thank
you.”, “How much?”)
Lip reading

Braille (Uncontracted)

Braille (Contracted)

Reading – If vision were not an obstacle, would
the applicant be able to read and understand
books, newspapers and magazines?
Communication Methods
Skill Level/Comments
Reading – Is the applicant able to read notes
and letters? If yes, please provide a writing
sample in the space provided.
Writing – Does the applicant use writing to
communicate with others?
Print-On-Palm
Has the applicant had any computer training in
the past? If yes, please describe including
current level of computer skills.
Please list any communication devices that the
applicant owns or uses. (Ex. Writing guides,
TTY, braillewriter, Telebraille, Telletouch, Fax,
Braille Display and Computer, TTY w/LVD.)
Please indicate if items are owned.

If applicant does not use formal language to
communicate, how does he/she indicate need
or express choices? (Gestures, objects, etc.)

Does applicant communicate through gestures, Describe:
object symbols, and/or behavior?

Does the applicant use pictures to
communicate?
Does the applicant use or own a
communication book (object, pictorial, or
written)?

Does the applicant communicate with the
general public? (ex. Restaurants, stores, etc.). Describe:

Does the applicant utilize an interpreter?
Type of interpreting:
HELEN KELLER NATIONAL CENTER
FOR DEAF-BLIND YOUTHS AND ADULTS
141 Middle Neck Road, Sands Point, New York 11050
(516) 944-8900 V, (516) 944-8637 TTY, (516) 944-7302 FAX
RELEASE FOR PUBLIC RELATIONS AND COMMUNITY EDUCATION

I hereby give my consent to the Helen Keller National Center for Deaf-Blind Youths and Adults to use
my name and/or photograph. This consent covers my name and/or photograph in brochures, releases,
television, radio, magazines and other public education media.
In granting this consent, I appreciate that it will be used in the best interests of not only the programs
conducted and the individuals served by the Helen Keller National Center, but in my best interests as
well.
CONFIDENTIALITY POLICY
Attention Parent/Guardian:
Please take a few minutes to read the following policy. If you have any questions, please feel
free to contact either your Regional Representative or the Admissions Coordinator at HKNC.

The Helen Keller National Center serves students sixteen years of age and older. Legally, students 18 years of age are adults and will be considered as such. Therefore, the student’s right to
confidentiality will be respected in all cases, except when a student clearly demonstrates danger to him
or herself or to others, or in cases where legal guardianship * has been established. The adult student
will be the primary decision maker in determining his or her program and social activities. Students will
be encouraged to include family members and others as members of their team of support.
I, , have read and understand the above.

Guardian
* Enclose copy of legal (court appointed) guardianship. PERSON/PERSONS COMPLETING SECTION I OF ADMISSION PACKET
Applicant Family Guardian Service Provider Signature Date


MEDICAL COVERAGE AGREEMENT
To be completed by applicant, parent or caregiver
A. Health Insurance Plan(s) covering the applicant:
Check if applicable
Address & Phone Number
Policy Number
BLUE CROSS
BLUE SHIELD
MEDICARE
MEDICAID
OTHER (Specify name)
OTHER (Specify name)
***PLEASE PROVIDE PHOTOCOPIES OF ALL INSURANCE CARDS***
(FRONT AND BACK)
B. Out-of-state Medicaid will only cover emergency room service while clients are in New
York. HKNC applicants are considered legal residents of their home states while they are in
training and therefore are not eligible for local Medicaid benefits. Please state
insurance/person/agency who will pay for each of the following if needed. Also, indicate who is
responsible for any co-payments. For example, Medicare has a 20% co-payment.
Each Section Must be
Primary Insurance or
Secondary Insurance
Person Responsible
Completed
Person Responsible
or Person Responsible
for Co-Payment
for Payment
for Payment
(i.e. self or parent)
PRESCRIPTIONS

DR. VISITS

HOSPITALIZATION
Please note that HKNC is not a Medicaid provider.
INFORMATION REGARDING MENTAL HEALTH HISTORY
HAVE YOU PARTICIPATED IN COUNSELING WITHIN THE PAST THREE YEARS? YES NO

IF YES, PLEASE COMPLETE THE FOLLOWING RELEASE OF INFORMATION SO THAT WE MAY
OBTAIN BACKGROUND INFORMATION:
I, ____________________, AUTHORIZE THE HELEN KELLER NATIONAL CENTER, TO OBTAIN
INFORMATION RELATED TO COUNSELING FROM:
Name, address and phone number of therapist:
___________________________________________________________________________________
_____________________________________________
Applicant/legal guardian signature:___________________ Date:_____________
THIS RELEASE IS VALID FOR 6 MONTHS

HAVE YOU EVER OR ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS
(OR ANY PSYCHIATRIC MEDICATIONS NOT LISTED BELOW)?
ANTIPSYCHOTIC
ANTIDEPRESSANTS
ANTICONVULSIVES
SOPORIFICS
Seroquel Remeron Abilify Wellbutrin Geodon Celexa Clozaril
IF YES, PLEASE COMPLETE THE FOLLOWING RELEASE OF INFORMATION THAT WE MAY
OBTAIN INFORMATION NECESSARY FOR ADMISSION:
I,____________________, AUTHORIZE THE HELEN KELLER NATIONAL CENTER TO OBTAIN
INFORMATION RELATED TO TREATMENT FROM:
Name, address and phone number of prescribing physician:
______________________________________________________________
____________________________________________________________
Applicant/legal guardian signature:_________________ Date:___________
THIS RELEASE IS VALID FOR 6 MONTHS
HELEN KELLER NATIONAL CENTER Section I – Page 10
FOR DEAF-BLIND YOUTHS AND ADULTS
141 Middle Neck Road, Sands Point, New York 11050
(516) 944-8900 V, (516) 944-8637 TTY, (516) 944-7302 FAX
MEDICAL CONSENT AGREEMENT
To be completed by independent adult, parent, legal guardian or conservator.
Name of Applicant:

Social Security No:

Permanent Address:
Indicate if applicant has ever had an allergic reaction to medications, pollen, food, other. Please describe reaction. Is applicant aware of allergy? Does applicant know the medications used and is he/she able to administer them? I, the undersigned, consent that HKNC may provide medical and related diagnostic and/or treatment services and share all records which the Center considers to be essential to treatment; and, in case of emergency, authorize the provision of medical and/or surgical treatment and sharing of all records with an appropriate clinic, hospital, or private practitioner. (Place an “X” in the appropriate box and complete the information below.) Applicant
Parent (if applicant is under 18 years of age)
Legal (court appointed) guardian*
Print Name Here:
Home Address:
Home Telephone Number:
Business Phone Number:
Authorizing Signature:
* This consent is given with the understanding that HKNC agrees to inform me as soon as practicable of the need for, and the results of, any emergency treatment provided under this consent.

Source: http://hknc.org/images/ADMISSIONS/ADM%20PKT%2007-SS%20Sec%20I.pdf