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REQUEST FOR ORIENTATION & MOBILITY (OM) SERVICES
2935 Universal Court
Oshkosh WI 54904
Phone: 920-233-2372 - Fax: 920-424-4378
Legal Name of Student:
School of Attendance:
Name of Parent/Legal/Guardian:
Cell Phone #:
DISTRICT CONTACT INFORMATION:
Type of Service Requested:
If "Other" is checked above, please indicate here the type of service requested:
Is an Ocular report available?
Name of Contact Person:
Email for Contact Person:
Phone for Contact Person:
Name of person submitting this i-form:
Name of district designee/director (designated to allocate funds):
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