[Greater-baltimore] FW: BISM Workshop for Seniors

National Federation of the Blind of Maryland nfbmd at riccobono.us
Thu Sep 13 14:06:38 UTC 2012


This sounds like a fantastic opportunity. As many seniors do not have email,
please consider calling seniors in your life with this valuable information.
Melissa

-----Original Message-----
From: Mollyne Honor [mailto:mrhonor at LBPH.LIB.MD.US] 
Sent: Wednesday, September 12, 2012 11:28 AM
To: LBPH_INFO-L at LISTSRV.MSDE.STATE.MD.US
Subject: BISM Workshop for Seniors

HURRY -- DON'T MISS OUT!

LIFE ENHANCEMENT WORKSHOP
for
Senior Citizens with Significant Vision Loss (pre-registration required)

WHAT:       FINAL WORKSHOP OF THIS GRANT YEAR

WHERE:     BLIND INDUSTRIES & SERVICES OF MD (BISM)
                 3345 Washington Boulevard
                 Baltimore, MD 21227   

WHEN:       September 27, 2012 - Thursday
                  10 am to 2:30 pm

INCLUDES: Demonstrations and Hands-on Instruction
                        .    Techniques for Independence
                        .    Aids, Appliances & Talking Devices
                        .    Technology & Computer Demos
                        .    Independent Living Skills
                        .    Intro to Braille & Communication
                        .    Travel Skills
                        .    Resource Packet for Every Participant
                        .    LUNCH ALSO INCLUDED!

... ALL AT NO COST 

For application or further information, please contact:

ANDY McIVER, amciver at bism.org, 410-737-2648

Registration limited - Please apply asap 

Proudly Sponsored by:
Blind Industries and Services of Maryland (BISM COMPASS LOGO) with funding
and support from MSDE - DORS/OBVS



 

	
	Workshop Location:
BISM-Baltimore
Workshop Date:
Sept. 27, 2012
	
Description: A_New_Black_Logo

Blind Industries and Services of Maryland

Life Enhancement Workshop

WORKSHOP APPLICATION

Part I

 

Applicant Information                                                      

Name:

Telephone:

Address:

Cell Phone:

 

E-Mail:

 

Date of Birth:

 

County:

Referred By:

Agency:

I am diabetic:      YES[    ]   NO[    ]

I am visually impaired:      YES[    ]   NO[    ]

Visual Acuity:    Right Eye_________   Left Eye __________

Medical Restrictions (diet, activity, etc.):

Other Disabilities:

Medications:

 

Allergies:

I am a Veteran:     YES[   ]    NO[   ]

 

Emergency Contact

Name:

Relationship:

Telephone (H):

Telephone (other):

Address:

 

 

 

Physician Information

Doctor's Name:

Telephone:

Address:

 

 

 

1.	I understand that I am responsible for my own transportation to and
from the workshop.

 

2.	I understand that BISM is not responsible for providing health
insurance or health care for me while I am participating in this program.  I
assume sole responsibility for my health insurance and all medical expenses.

 

3.	I understand that pictures or videos may be taken during training
time for rehabilitation department photo 

      albums and/or BISM public relations purposes.

 

4.	I will not hold Blind Industries and Services of Maryland liable for
injuries and damages as a result of 

participation in this program. 

 

            ____________________________________________
____________________

            Signature
Date

	
	**For Staff Use Only**
Application reviewed. All sections complete.
Staff Initials: ______Date: ______
	
LOCAL BISM CONTACT:
Baltimore, MD
Andy McIver amciver at bism.org 410-737-2648 888-322-4567 

 

 

 


                                         




 

Description: A_New_Black_Logo




 

                   BLIND INDUSTRIES and SERVICES of MARYLAND

WORKSHOP APPLICATION

Part II

 

 

          




Name: _____________________________________

 

 

Age:

55-59                        95-99

60-64                        100 & over

65-69                        

70-74

75-79

80-84

85-89

90-94

 

Gender:   Male           Female

 

Race/Ethnicity: 

Hispanic/Latino

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Two or more races (not Hispanic/Latino)

Unknown (only if consumer refuses to identify)

            

Degree of Visual Impairment:

Totally Blind (LP or NLP)

Legally Blind (excluding totally blind)

Severe Visual Impairment

 

Major Cause of Visual Impairment:

Macular Degeneration

Diabetic Retinopathy

Glaucoma

Cataracts

Other

	
		
 


Other Age-Related Impairments: 

Hearing Impairment

Diabetes 

Cardiovascular Disease and Stroke

Cancer

Bone, Muscle, Skin, Joint, and Movement Disorders

Alzheimer's Disease/Cognitive Impairment

Depression/Mood Disorder

Other Major Geriatric Concerns

 

 

 

 

 

 

 

9.19.12 scr

 

 

 

Type of Living Arrangement:

Lives Alone

Live with Others (family, spouse, caretaker, etc.)

 

Type of Residence:

Private Residence (house or apartment)

Senior Living/Retirement Community

Assisted Living Facility

Nursing Home/Long Term Care Facility

 

Source of Referral:

Eye Care Provider (ophthalmologist, optometrist)

Physician/Medical Provider

State VR Agency

Government or Social Service Agency

Senior Program

Faith-Based Organization

Independent Living Center

Family Member or Friend

Self-Referral

Veterans Administration

Other

 

 


www.bism.org

 

 

 

________________________________

No virus found in this message.
Checked by AVG - www.avg.com
Version: 10.0.1424 / Virus Database: 2437/5264 - Release Date: 09/12/12

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