BEAM_WksApp | National Federation of the Blind of Missouri

Be Your Own Champion Workshop Application

Tips for Navigating Self-Advocacy

Thank you for your interest in participating in the National Federation of the Blind of Missouri’s “Be Your Own Champion” workshop for transition age students on January 17,2026 from 9:30 AM to 3:30 PM. We encourage parents and students to review and complete this form together.

Parent/Guardian

Parent/Guardian Name

Parent/Guardian Phone Number

Parent/Guardian Email Address

Student

Student's Name

Student's Date of Birth

Student’s Education Status and/or Grade

Does the student have an open case with Rehabilitation Services for the Blind (RSB)?

Who is their counselor?

Are you and your student interested in opening a case and/or learning more about RSB?

Student's Phone Number

Student's Email Address

Address

Address Line 1

Address Line 2

City

State

Zip Code

Workshop Questionnaire

What type of educational setting is the student currently in?

How does the student typically handle advocating for themselves?

In what situations does the student feel the most confidence in self-advocating (with friends, educators, family, etc)?

In what situations does the student struggle with self-advocating (friends, educators, family, etc.)?

Are there any specific questions you and/or the student have that we can answer during the workshop?

Medical/Emergency

Name of emergency contact

Emergency contacts relationship to student

Emergency Contact Phone Number

Does the student have any medical conditions?

Medical Conditions Explained

Does the student take medications?

Medications Listed

Will the student need to take any medication during the workshop?

Workshop Medication Details

Does the student have any food allergies or special dietary restrictions?

Allergy/Dietary Restrictions Explained

Is there anything else you and your student would like us to know about him/her?

Permissions

Does the Program Coordinator have permission to seek medical attention for the student in the event that a medical emergency occurs?

During this workshop photos may be taken and some or all of the activities may be recorded. These photos and recordings will be used for future education, documentation, and advertising purposes. Please answer the following questions to indicate you and your student’s preferences.

Thank you for completing the form. By electronically signing this form you and your student are stating that you have read and understand the information above.

Parent/Guardian Signature

By signing your name electronically, you are agreeing that your electronic signature is the legal equivalent of your manual signature on this Form.

Student's Signature