2nd Annual Adventures in Braille
Braille Music Immersion Weekend
Friday, January 13, 2012 through Monday, January 16, 2012
Camp is Free!
Application Deadline – December 15, 2011
Space is limited so please register early
Eligibility RequirementsCampers must:
• Have a vision loss that affects learning;
• Be a South Carolina resident;
• Be between the ages of 11 and 18;
• Be toilet-trained;
• Have the physical, mental and behavioral capabilities to benefit from the programs offered during the camp;
•Have an interest in learning or improving braille skills.
Yes, my child meets all of these eligibility requirements.
Signature of Parent/Legal Guardian______Date______
Personal Information
Child’s Name______(Nickname) ______Sex ____ Age ______
Address ______Date of Birth ______
City ______State ______County______Zip ______
E-Mail Address:______
Father’s Name ______Home Phone # ______Work Phone # ______Cell # ______
Mother’s Name ______Home Phone # ______Work Phone # ______Cell # ______
Has your child participated in camp(s) before? ______If yes, camp name(s) and date(s)______
______
T-Shirt Size: Child’s M Adult S Adult M Adult L Adult X-L Adult XX-L Adult XXX-L
How did you learn of this camp? SCSDB Mailer Newspaper My Child’s Teacher or School Staff Other ______
Visual Impairment: Eye Condition ______
Visual Acuity Best Correction: Near Vision: Left ______Right ______Far Vision: Left ______Right ______
Reading Style:Braille Large Print Regular Print Glasses:Yes No Cane for Mobility:Yes No
Wheelchair:Yes No Other Disabilities (Please List) ______
Behavioral Concerns? ______Are there any other special needs (physical or emotional)
that we should be aware of? ______
School Information
Name of School Currently Attending ______Grade ______
City ______State ______Zip Code ______
School Phone # ______Name of Child’s Teacher______
School District______
Medical Information
Child’s Name ______Social Security #______Medicaid #______
How is health care provided for this child? Employment InsurancePrivate Insurance Medicaid Other
Name of Insurance Company______Policy #______
Does your child have health problems? Please check:
Allergies, please list (food, medicine, other)Anemia Asthma Diabetes Heart Problems
Seizures/Convulsions Sickle Cell Anemia
Are there any other special needs we need to be aware of?______
Does your child take medication?______Name of medication(s)______
Dosage and frequency ______
Date of last Tetanus shot ______
Emergency Information
Please give us the names of two relatives or close friends whom we can call in case the parent/guardian cannot be reached.
Name______Phone______
City/State/Zip______Relationship______
Name______Phone______
City/State/Zip______Relationship______
All scheduled activities (both on and off campus) are closely supervised. Please check yes or no to the following questions.
1. I give my son/daughter permission to use the SCSDB swimming pool facilities with a certified lifeguard present.
❏ Yes ❏ No Special Restrictions: ______
2. My child may ride in a school vehicle to attend special off-campus activities.
❏ Yes ❏ No Special Restrictions: ______
3. I want my child to ride the bus/car to and from camp. Transportation routes to camp will be based on campers who have
registered by December 15thand will be communicated two weeks before camp begins.
❏ Yes ❏ No Special Restrictions: ______
4. My child has permission to access the Internet or the school’s computers following the SCSDB Policy for Acceptable
Use of theComputer Network. ❏ Yes ❏ No Special Restrictions: ______
5. I give my permission for pictures/video tapes to be taken of my child. These pictures/video tapes may be used
to create the assessible website that focuses on braille literacy and how to infuse braille into everyday life. I
understand that the video made may be viewed by anyone associated with the website and become property of the
University of South Carolina Upstate. ❏ Yes ❏ No Special Restrictions:______
6. I give permission for my for pictures and videos made to be used on the BrailleSC.org website. Personal information,
street addresses and email addresses will NOT be publicly posted at any time. ❏ Yes ❏ No Restrictions: ______
7. I understand that I am responsible and financially liable for the medical care of my child. In case of an emergency
and I cannot benotified, the school has permission to treat and to order injections, anesthesia or surgery for my
child.
______
Signature of Parent/Guardian Date
Please return completed application form to:
Kim Speer
SCSDB
355 Cedar Springs Rd.
Spartanburg, SC 29302
Questions? Please contact Dr. Tina Herzberg at 864-503-5572
Camp is Free Application Deadline – December 15, 2011
Space is limited so please register early