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Instructions for Completing APH Registration

Instructions for Completing
Registration Form

Numbers correspond with numbering on registration form.

1. Agencies must have a parent's (or guardian's) permission to release confidential data to the APH. Please mark the box with an X if the parent has given permission to release data to the APH. If the parent denies permission, the student will be ineligible for the federal quota program. The school system must maintain on file a record of the parent's consent. The document must be written, signed, and dated; specify any information that will be released; state the purpose of the release; and identify the entities or individuals to whom the release will be made. Documentation should remain with the education record as long as the education record is maintained. The requirement for positive parental consent before releasing confidential student information is a provision of the Family Education Rights and Privacy Act (FERPA, 20 USC Section 1232g; Title 34, Federal Code of Regulations, Part 99) and its counterpart, California Education Code Section 49060. These requirements extend to nonpublic schools operating under contract with a public school.
   
   Checking this box indicates that the agency confirms that the student meets the following criteria: Central visual acuity of 20/200 or less in the better eye with best correction; a peripheral field so contracted that the widest diameter of such field subtends an angular distance no greater than 20 degrees; or visual performance reduced by a brain injury or dysfunction when visual function meets the definition of blindness as determined by an eye care specialist or neurologist.
   
   
2. Enter the student’s full name, only one student per form.
   
   
3. Enter the student's date of birth.
   
   
4. Mark the appropriate box with an X for the gender of the student.
   
   
5. Enter the student's grade level. “Key to Grade Placement Codes” is enclosed to assist you in determining the proper code.
   
   
6. Enter any additional disabilities of the student.
   
   
7. Indicate the student’s eye acuity (vision). Check either the MDB or FDB category. If you select MDB check the box that applies. Refer to the eye doctor's report to determine the acuity. (See chart on next page.)
   
   
8. Mark the box with an X indicating the student’s Primary Reading Medium.
   
   
9. Check one box that applies, indicating the student’s Secondary Reading Medium. (Required Category)
   
   
10. Check one box if applicable, indicating the student’s Third Reading Medium. (Optional Category)
    
    
11. Check the box or enter the primary language spoken by a student in the classroom.

Vision Measurement and Reporting Codes