Wisconsin
Braille Inc.
Braille
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 student’s Braille reading level: _________________________________
_____________________________________________________________________
Interests: ____________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Needs/Preferences:______________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Parent Signature: _______________________________ Date: __________________
Mail form to:
Cheryl Orgas,
or