Thank You for Showing an Interest in Deafblind Camp of Texas! s1

Camper 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 acceptance letter will be sent around March 1st.

If you are accepted, $350.00 will be due on May 1st.

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: Hard of Hearing Deaf

Vision: Blind Night Blindness Only Tunnel Vision Usher Syndrome Other ______

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

Camp schedule & menu in Braille?: Yes No

Will you be bringing a service animal? Yes No

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 DeafBlind Campers will be placed at the main house. There are two (2) bedrooms with a total of fourteen (14) bunk beds each. Some are full-sized while others are twin-sized. Each bedroom will come with their own bathrooms. Bed linens will be provided, but you are welcome to bring your own. The gentlemen will be placed in the right bedroom while the ladies will be placed in the left bedroom. The main house is also mobility accessible.

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):

______

______

Will you be bringing a Personal Attendant (PA)? (SSPs cannot provide personal care, e.g., bathing and grooming. Only the PA can do. Furthermore, the PA will be required to pay the full amount of camper fee as well):

Yes No

Emergency Contact Information

Full Name: ______

Relationship: ______

Emergency Phone: ______

Doctor Name: ______

Insurance Company: ______

Insurance Policy Number: ______

Communication Access

When I communicate with other people, I use:

ASL (American Sign Language) PSE (English sign and ASL mixed) English Sign Fingerspelling

Spoken English Other ______

Which is your dominant hand?:

Right hand Left hand Either one N/A

When other people communicate with me, I prefer they use:

ASL (American Sign Language) PSE (English sign and ASL mixed) English SIgn Fingerspelling

Spoken English Other ______

I prefer to use:

Platform Interpreter(s)

Tactile (touch) Interpreter(s)

Close Vision (CV) Interpreter(s)

FM System or Voicing Interpreter(s)

Other ______

Matching Preferences

Any SSP you prefer to be with?:

______

______

Any SSP you prefer NOT to be with?:

______

______

Sex Preference?: Male Female No preference

Additional Information to help matching SSP(s) better?:

______

______

______

______

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!