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TLVC Parent Questionnaire

Clinic Location

Additional locations to be added once confirmed

Medicine Hat, January 22nd	Calgary, February 7th	Red Deer, March 20th
Lethbridge, January 23rd	Edmonton, February 13th & March 19th	Grande Prairie, April 18th

Name of Person Completing Form

First name
Last name
Email	Email is already used by another user

Child Information

Legal name of Child	An answer is requiredLegal name of Child
Parents/Guardians	An answer is requiredParents/Guardians
Home Phone	An answer is requiredHome Phone
Work Phone	An answer is requiredWork Phone
Parent email	An answer is requiredParent email

School Name and City/Town

Medical

Family Doctor:	An answer is requiredFamily Doctor:
Ophthalmologist:	An answer is requiredOphthalmologist:

Is your child generally in good health?

Yes

Are there any medical issues we need to be concerned about at the TLVC assessment?

Yes

What concerns do you have related to your child's vision?

Date of Last Eye Appointment

10.

When did your child's vision loss begin/occur?

11.

Does your child watch TV or play video games?

If yes, at what distance?

12.

Is your child's vision challenged by bright light/direct sunlight?

Yes

13.

Does your child read print?

If yes, what size?

14.

Does your child use optical devices at home?

Yes

15.

Is your child involved in any community programs/sports?

Yes

16.

To complete this referral we require a signature of the parent or legal guardian. Please click this link to download and print the parent consent form:

Once completed please scan the signed document (or save if electronically signed) and add it to this referral by uploading the file.

Download and print parent consent form
Fill out and sign form
Scan and save the signed form to your computer
Upload the signed form to this document using the Choose File button.

Alternatively a scan or high quality photo of the signed consent form can be sent to: edc.liss@gov.ab.ca

The referral cannot be processed until the parent/guardian signature is received

Parent Signature

This personal information is collected pursuant to section 33(c) of the Freedom of Information and Protection of Privacy Act. This personal information is being collected to determine eligibility to participate in Alberta Education’s Travelling Low Vision Clinic (TLVC). The personal information will also be used and disclosed to the members of the TLVC team for the assessment and provision of educational programing for children and youth with low vision. The assessment report developed by the TLVC will only be shared with individuals approved by the child or youth’s parents or guardians. Questions regarding the collection may be directed to the Director, Learner Supports, Alberta Education, 8^th Floor, 44 Capital Boulevard, 10044-108 Street, Edmonton, AB T6J 5E6 or by telephone at 780-422-5045.

(Dial 310‐0000 to be connected toll‐free from outside the Edmonton area.)

Please click on the icon below to submit your referral