Application Checklist
Student Name: _________________________________________________
In order for the application to be complete, the following items need to be in the packet with INSIGHT
fee and mailed to:
Beth Baker
KSB
1867 Frankfort Ave.
Louisville, KY 40206
MSU Undergraduate Student Application Form
INSIGHT Student Medical Data Form
Eye Report (get copy from school)
Individual Learning Plan (ILP) or Planned Course of Study (get copy from school)
Individual Education Program (IEP) or 504 Plan (get copy from school)
MSU Caudill Clinic Health Form (please make sure to sign all sections on the back page)
Copy of Immunization Record (get copy from school)
Copy of Medical/Insurance Card
Medical/Dental Release Form
General Permissions Form
Rules of Conduct/Expectations Form
Copy of Functional vision/ Learning Media Assessment (get copy from school)
If applicable, Copy of Orientation and Mobility Assessment (get copy from school )
$75 Registration Fee addressed to KEDC and in the memo section write INSIGHT Fee
($25 will be placed on the student ID for use during the program)
Additional Comments/Notes: