Request for O&M

REQUEST FOR ORIENTATION & MOBILITY (OM) SERVICES

2935 Universal Court
Oshkosh WI  54904
Phone: 920-233-2372 - Fax: 920-424-4378

1.
*

Legal Name of Student:

2.
*

Gender:

Male
Female
3.
*

DOB (M/D/Y):

4.
*

Grade:

5.
*

School District:

6.
*

School of Attendance:

7.
*

Name of Parent/Legal/Guardian:

8.
*

Address:

9.
*

City/State/Zip:

10.
*

Phone Number:

11.

Cell Phone #:

 

DISTRICT CONTACT INFORMATION:


 

12.
*

Type of Service Requested:

(1 required)
Student Evaluation
Student Re-Evaluation
Consultation
Transfer Student Needing Services
Other
13.

If "Other" is checked above, please indicate here the type of service requested:

14.
*

Is an Ocular report available?

Yes
  No
15.

Other Comments/Notes:

16.
*

Name of Contact Person:

17.
*

Email for Contact Person:

18.
*

Phone for Contact Person:


 

19.
*

Name of person submitting this i-form:

20.
*

Name of district designee/director (designated to allocate funds):

* Enter Your Email Address:

I am not a Robot

  

  • Main Office & All Mail:
  • 2935 Universal Ct
  • Oshkosh, WI 54904
  • Phone: 920-233-2372
  • Fax: 920-236-0580
  • Conference Center
  • 2300 State Road 44
  • Oshkosh, WI 54904
  • Phone: 920-233-2372
  • Fax: 920-424-3478