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Pathways Program Teacher Form

Submit Teacher Form

Fill out the form below, or download the PDF/Word application and submit it at Pathways Submissions or [email protected]

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This field is for validation purposes and should be left unchanged.

2026 Teacher Form

To be completed by the student’s teacher.

Student Name (Teacher Form)(Required)

VI Teacher’s Name(Required)

First Last

VI Teacher’s Email Address(Required)

Student’s School

School Address

Street Address Address Line 2 City State ZIP Code

School Phone

Current grade level of student

Visual acuity – Left Eye

Visual acuity – Right Eye

Does the student have or require a one-on-one aide?

Yes

If yes, please explain (one-on-one aide)

Has the student ever displayed behavioral problems with you, other adults, or peers?

Yes

If yes, please explain (behavioral problems)

Has the student ever displayed disruptive social emotional behavior?

Yes

If yes, please explain (social emotional behavior)

Can this student travel independently inside buildings?

Yes

If no, please explain (independent travel)

Travel with a cane?

Yes

If no, please explain (cane travel)

Please check the following

Does the student enjoy playing with others?

Yes

Unknown

Like team projects:

Yes

Unknown

Like team sports:

Yes

Unknown

Show satisfactory academic performance?

Yes

Unknown

Take initiative before being told what to do:

Yes

Unknown

Have a good attitude toward supervision?

Yes

Unknown

Easily follows instructions?

Yes

Unknown

Complete tasks in a reasonable amount of time:

Yes

Unknown

Rank the student’s competency in the following areas

Budgeting

Good

Poor

Unknown

Task planning

Good

Poor

Unknown

Task completion

Good

Poor

Unknown

Mobility

Good

Poor

Unknown

House cleaning

Good

Poor

Unknown

Hygiene

Good

Poor

Unknown

Team sports

Good

Poor

Unknown

Physical exercise

Good

Poor

Unknown

Overall maturity

Good

Poor

Unknown

Signature of VI Teacher

Teacher Signature Date

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17 N. State Street
Suite 1050
Chicago, Illinois
60602-3510

312-236-0808

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Blind Service Association (“Blind Service Chicago”) is a 501(c)(3) tax-exempt organization. Contributions to BSC are tax-deductible to the extent permitted by law. Our Federal Identification Number (EIN) is 36-2240484