Thank You for Showing an Interest in Deafblind Camp of Texas!

SSP Application 2017

Thank you for showing an interest in DeafBlind Camp of Texas!

You will need the following to fill out this application

●  About 10 minutes

●  Emergency Contact Info

●  List of your medications

●  Insurance Card, if you have one

The final deadline for submitting the application is AS SOON AS POSSIBLE!!!

Communication and Code of Conduct Policy

The DeafBlind Camp of Texas (DBCTX) respects the communication preferences of all the campers who attend camp. Since all campers have some degree of hearing loss and vision loss, communication modes may include spoken language, sign language, use of assistive devices, or a combination of all. All volunteers and workers at the camp will strive to use the communication mode or modes preferred by the camper. The camp’s goal is for inclusion of all participants.

The Peaceable Kingdom and DBCTX have a zero tolerance policy for alcohol and illegal drugs. Individuals attending or volunteering at the DeafBlind Camp of Texas must not bring alcohol or illegal drugs into camp, come onto the camp grounds while intoxicated, or smoke in non-designated smoking areas. Anyone who breaks this policy will be asked to leave camp immediately.

I have read and agree to follow the policies set by the DBCTX Board of Directors.

Permissions

I acknowledge, agree, and do hereby release from all liability and hold harmless DeafBlind Camp of Texas and any of its employees representing or related to the DeafBlind Camp of Texas. This liability release is for any and all liability for personal injuries including death and property losses or damage in connection with any activity or accommodation of the above mentioned business. The undersigned does hereby further agree to abide by all the rules and regulations that are presented by DeafBlind Camp of Texas.

I consent to receive emergency medical treatment in event of illness or injury and release and forever discharge above mentioned Business from any liability or claim whatsoever what arises or may later arise on account of medical services rendered in connection with an emergency during participation in the Program

I hereby irrevocably authorize the above mentioned business to edit, alter, copy, exhibit, publish, or distribute these photos, images, videos, or audio recordings for any lawful purpose. I waive any claims or any right to royalties or other compensation arising or related to the use of the photo.

I have read and grant permission to above mentioned business.

Personal Information

Full Name: ______

Email Address: ______

Date of Birth: ______

Full Address: ______

______

Phone: ______

Type of Phone Number: Voice Text Videophone

Sex: Female Male Other ______

Hearing: Hearing Hard of Hearing Deaf

Vision: Blind Night Blindness Only Sighted

Tunnel Vision Usher Syndrome

Other ______

Height: 5'4" or less 5'5" - 5'9" 5'10" or more

Do you use any mobility aid(s)? Wheelchair Walker(s) Other ______

Any activities or skills you want to share and / or lead at camp? (e.g cooking class, art & crafts, etc):

______

______

How did you learn about the camp? (e.g. Through friends):

______

______

Opt in the Camp Directory (Only your full name, city, state, email address, and phone number will be shared):

Yes No

Lodging

All SSP volunteers will be placed at the retreat’s two (2) log cabins (adjacent to each other). Linens are provided, but you are welcome to bring your own. Each cabin has a total of nineteen (19) beds; a loft with five (5) twin-sized beds, twelve (12) twin-sized bunk beds, and a backroom with two (2) twin-sized bunk beds. Each cabin also comes with two (2) toilets, showers and sinks, and a small kitchen with a refrigerator.

It is truly a slumber party! Smile!

Food

Are you a Vegetarian?: Yes No

Are you a Vegan?: Yes No

Any Dietary restrictions or Food allergies?:

______

______

Transportation

Everyone is responsible for finding their transportation. Transportation to and from the camp will be provided at only 3 locations in Austin; the airport, Greyhound Bus Stop, and MegaBus Bus Stop. If you are accepted, a transportation form with more details will be shared with you.

Do you understand?: Yes

Medical Information

We do have a registered nurse on site. We can store medications that need to be refrigerated. You are responsible to bring and take your medicines. We cannot administer prescription medications without a prescription.

Do you understand?: Yes

Do you smoke?: Yes No

Please check any of the following you may have:

Diabetes Heart Problem High Blood Pressure

Thyroid Problem Epilepsy or Seizures Asthma

Hypoglycemia

Describe any other health conditions:

______

______

Name any medications you are taking:

______

______

Name any recent surgeries:

______

______

Name any medical or environmental allergies (e.g. Aspirin, Dogs):

______

______

Emergency Contact Information

Full Name: ______

Relationship: ______

Emergency Phone: ______

Doctor Name: ______

Insurance Company: ______

Insurance Policy Number: ______

Communication Access

Do you have Sign Language skills?:

No, I do not have sign language skills

Yes, I'm learning, but not fluent

Yes, I am a fluent sign language user

Yes, I am a native sign language user

Do you have Tactile Sign Language skills?:

No, I do not have tactile sign language skills

Yes, I'm learning, but not fluent

Yes, I am a fluent sign language user

Yes, I am a native sign language user

Which is your dominant hand?:

Right hand Left hand Either one N/A

Mark the highest level ASL course and any other courses that you have taken:

ASL I ASL II ASL III ASL IV ASL V+

Deaf Studies Courses DeafBlind focused Courses

Interpreting Courses ______

List any certifications (e.g. NIC, BEI, etc): ______

Matching Preferences

Are you comfortable working with a DeafBlind camper who has a service animal?: Yes No

Which do you prefer to work with?:

Male Female No preference

Please list the names of those you would prefer to be paired with. Please only enter one name per field; so we may try to accommodate your request(s):

______

______

______

Please list any names of those you wish to not work with. Please only enter one name per field; so we may try to accommodate your request(s):

______

______

______

Preferred shift to be off?: Morning Afternoon Evening No preference

Additional information to help match you with SSP(s) and camper(s)?:

______

______

SSP Experience

Explain your experiences as a SSP (if any):

______

______

______

Have you attended any DeafBlind Camp before? List Years.:

______

______

______

Commitment

I understand that I am volunteering my time at camp to support campers who are DeafBlind. The number of DeafBlind individuals we accept GREATLY depends on every volunteer’s full commitment to the entire duration of the camp. In exchange for my time, I will be provided training and experience on DeafBlind etiquette, human guide, providing visual and environmental information. In addition, my room and board will be paid by DeafBlind Camp of Texas.

I am committed to volunteer my time to DeafBlind Camp of Texas.

Thank you

Thank you for applying to DeafBlind Camp of Texas! (If you don’t hear from us within 48 hours of submission, it means we never got the application.)

Please mail to

DeafBlind Camp of Texas

2504 Wildlife Run

Cedar Park, TX. 78613

Federal Postal regulations allow certain mail to be sent to or from blind or other print-handicapped persons free of postage. Mail sent as free matter must be marked "Free Matter for the Blind or Handicapped" in the upper right corner of the address side.

Thank you!