Forms


 
How to schedule a KanLovKids Clinic
Low Vision Evaluation Clinic (LVEC) or 
Pediatric Low Vision Collaboration Clinic (PLVCC)

Please contact your KSSB Regional Field Services Specialist  to schedule a clinic in your area and to discuss which type of Low Vision Clinic would be more appropriate.  
Please note: Schedules will be completed with your Regional Field Services Specialist. Please have the name and phone number of the the child's doctor, school district name & number, & contact info for person driving available.
Questions? -- contact KanLovKids Coordinator, Judy Imber      jimber@kssdb.org    913-305-3043

 Area ServedField Services Specialist  PhoneEmail 
 Northeast Region Nancy Mann 913-787-5190nmann@kssdb.org
 Southeast Region Judy Imber913-305-3043jimber@kssdb.org  
 Central/North Central Region Anna Cyr913-645-5324 acyr@kssdb.org
 South Central RegionDebbie Moody913-982-7712 dmoody@kssdb.org
 Western Region:Menely Hogan 913-645-2659mhogan @kssdb.org

To see which Field Services Specialist serves your area click here for a map.
  • The Regional Field Services Specialist will contact the doctor’s office to setup a date and time for the evaluations and then work with you to arrange the Clinic Schedule.
  • Forms for the clinics (Low Vision or Pediatric Low Vision Collaboration Clinic) can be downloaded from the KanLovKids website at http://kanlovkids.kssdb.org in a pdf format.
To see which Field Services Specialist serves your area click here for a map.

Information needed for Low Vision Evaluation Clinic are: When emailing documents, please put clinic date in the subject box.
  1. Consent Form
  2. Contact Information Form (Use Child/Student’s Legal Name)
  3. Patient's Eye Doctor Information
  4. Provide the most recent Eye Report, Functional Vision/ Learning Media Assessment, Clinic Low Vision Evaluation, and Orientation and Mobility Report
  5. Media Consent Form 
  6. Low Vision Clinic Parent Letter (please fill this out BEFORE sending it home to parents --parents keep this)
  7. Impact of Vision Impairment for Children (IVI-C for 8 to 18 years of age). This form should be completed online now, as it will be automatically scored. 
Please email documents (1-5) to Erin Kelly  ekelly@kssdb.org   913-305-3061      ALL DOCUMENTS ARE  DUE ONE MONTH BEFORE CLINIC DATE  
BRING SAMPLES OF STUDENT’S WORKSHEETS, TEXTBOOKS, ETC.


Information needed for Pediatric Low Vision Collaboration Clinic are: When emailing documents, please put clinic date in the subject box.
  1. Consent Form
  2. Contact Information Form (Use Child/Student’s Legal Name);
  3. Child-Student Eye Doctor's Information
  4. Child Family History Form
  5. Release form from Dr. Linda Lawrence's office (only needed for Dr. Lawrence's clinics)
  6. Provide the most recent Eye Report, Functional Vision/ Learning Media Assessment, Clinic Low Vision Evaluation, and Orientation and Mobility Report
  7. Media Consent Form
  8. Parent / Guardian Pediatric Low Vision Collaboration Clinic Letter (please fill this out BEFORE sending home to parents--parents keep this)
Please email documents (1-7) listed to Erin Kelly  ekelly@kssdb.org   913-305-3061      ALL DOCUMENTS ARE  DUE ONE MONTH BEFORE CLINIC DATE  
BRING SUPPORTED SEATING EQUIPMENT AND TRAVEL OR WHEELCHAIR TRAYS, ALONG WITH TOYS OR OBJECTS THE CHILD PREFERS.
________________________________________________________________________________________________________________
  • Erin Kelly will upload the completed documents in KSSB’s Google Drive so that the doctor will have on-line access to prepare for the evaluation.
  • After the evaluation, a report will be generated by the doctor and distributed to you to deliver to the family and school.
  • KSSB will send an invoice to your district after completion of the LVE or PLVCC for the children/students assessed.  The invoice will be sent to the designated person indicated by you on the Contact Information Form.

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