BSC Pathways Program Application

Submit Your Application

Fill out the form below, or download the PDF/Word application and submit it via Pathways Submissions or [email protected] along with all required materials.

All applications must include the following required materials and can be submitted with the link above or email.

Signed Waiver of Liability, Photo Release, & Release of School Information
VI Teacher Form

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Company

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Blind Service Chicago – Pathways 2026 Application Packet

Please complete the following sections. Use the Next button to proceed through the application.

Child’s Information

Child’s Name(Required)

First Last

Child’s Address(Required)

Street Address City State ZIP Code

Child’s Phone

Child’s Email

School Name

Grade in Fall of 2024

Identified Gender

Birthdate

MM slash DD slash YYYY

Parent/Guardian Information

Parent/Guardian Name(Required)

First Last

Parent/Guardian Address

Street Address City State ZIP Code

Phone Number (Home)

Phone Number (Work)

Phone Number (Cell)

Parent/Guardian Email(Required)

Emergency Contact (MUST BE INCLUDED)

Emergency Contact Name(Required)

First Last

Relationship to Child(Required)

Emergency Contact Phone(Required)

Student Questions

For the benefit of your child and to maximize their opportunities at Pathways, please provide thorough answers.

Has your child undergone any operations or sustained serious injuries?

Yes

If yes, please explain (operations/injuries)

Does your child use any of the following? (Check all that apply.)

Wheelchair

Walker

Support Cane

Hearing Aid

Can your child carry five pounds of groceries for one city block?

Yes

Can your child withstand sun exposure for one-half hour?

Yes

Is blindness the child’s only disability?

Yes

If no, please explain (other disability)

How would you describe your child’s level of activity?

Constantly on the go

Likes a lot of physical activity

Moderately active, likes some physical activity

Prefers slower paced indoor activities

Doesn’t like to be active at all

Does your child have any behavioral condition that may impede them or other students from participating in any activities?

Yes

If yes, please explain (behavioral condition)

Dietary, Allergies, and Medications

Does your child have any dietary restrictions (vegetarian, vegan, lactose intolerance, gluten intolerance, nut allergies)?

Yes

If yes, please explain (dietary restrictions)

Does your child have any allergies?

Yes

If yes, please explain (allergies)

Is your child currently taking any medications?

Yes

If yes, please explain (medications)

Registration Fee & Deadlines

Early registration fee (before May 21) is $100 per application; after May 21 it is $120.
To qualify for free curb-to-curb transportation, applications are due June 10; otherwise the registration deadline is June 18.

Waiver of Liability for Pathways

By continuing, you acknowledge and agree to the waiver terms for participation in Blind Service Chicago’s Pathways program, including travel and activities, and consent to medical treatment/first aid as needed.

(This is a condensed display for online submission. If you need the full waiver language, use the PDF packet provided.)

Waiver Agreement(Required)

I agree to the Waiver of Liability terms.

Doctor’s Name

Doctor’s Phone Number

Doctor’s Practice Address

Signature of Parent/Guardian(Required)

Waiver Signature Date(Required)

MM slash DD slash YYYY

Name of Parent or Guardian (print)(Required)

Name of Child(Required)

Photo Release

I give permission for Blind Service Chicago to take my child’s photograph for use to promote programs of BSC and for general interest for the common good of the blind and low vision community.

Photo Release

Yes, I give permission.

Parent/Guardian Signature (Photo Release)

Release of Information

I give permission to the resource teacher to release all information requested on the teacher form to BSC for determining eligibility for Pathways.

Parent/Guardian Name (Release of Information)

Child’s Name (Release of Information)

Parent/Guardian Signature (Release of Information)

Release of Information Date

MM slash DD slash YYYY

Release of School Information (for TVI/O&M form)

I authorize my child’s TVI and, if applicable, O&M Specialist to share the information in the TVI/O&M form with BSC to help determine eligibility and plan supports.

Parent/Guardian Name (Release of School Information)

Parent/Guardian Signature (Release of School Information)

Release of School Information Date

MM slash DD slash YYYY

PDF & Word English

Download PDF Download Word

PDF & Word Spanish

Download PDF Download Word

Please submit the application and required materials at Pathways Submissions or [email protected]