Low Vision Collaboration Clinic + Forms


A Low Vision Collaboration Clinic+ (LVCC+)is for infants, toddlers or school-aged children who have alternative communication and complex needs.

Information needed for  Low Vision Collaboration Clinic+ are: When emailing documents, please send individually and put clinic date in the subject line.
  1. Consent Form for Onsite Clinic  OR  Consent Form for Virtual Consultation
  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) Do not write KanLovKids on it
  6. Provide the most recent Eye Report, Functional Vision/ Learning Media Assessment, Clinic Low Vision Evaluation, Medical Records and Orientation and Mobility Report
  7. Media Consent Form (not needed for virtual clinics)
Please email documents (1-7) listed to Erin Kelly ekelly@kssdb.org 913-305-3061 
 AND  Judy Imber  jimber@kssdb.org  913-645-5843  
ALL DOCUMENTS ARE  DUE ONE MONTH BEFORE CLINIC DATE (be sure to indicate if ASL or Spanish interpreter is needed)
BRING SUPPORTED SEATING EQUIPMENT AND TRAVEL OR WHEELCHAIR TRAYS, ALONG WITH TOYS OR OBJECTS THE CHILD PREFERS.