KanLovKids Program
Form to be Completed by TSVI/COMS
To be completed by the Teacher of Students with Visual Impairment or Certified Orientation & Mobility Specialist:
Student's Name
Student's Address
Gender
Name of TSVI
Name of COMS
Infant/Toddler Contact
Agency Name or District Name AND USD number (this information is used for billing and/or recording keeping and must be completed for ALL participants 0-21 years old.)
USD/Agency Contact Name
Address
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