Greetings from CNIB Lake Joseph Centre!
2013 CNIB Lake Joe SCORE 3 Program Application Form
Monday, July 22, 2013 - Friday, July 26, 2013
Located in the heart of Muskoka, CNIB’s Lake Joseph Centre is a fully accessible lakefront facility that provides a unique blend of recreation and vision rehabilitation in a safe, inclusive environment. A wide range of summer programs are available to people of all ages with varying degrees of vision loss.
Join us this summer and enjoy:
o Fun-filled programs for youth, adults and families
o Outdoor activities like boating, hiking and swimming
o Music, crafts, campfires and other relaxing leisure activities
o The natural beauty of our vast waterfront and newly-renovated, fully accessible facilities
CNIBLake Joe is proud to be offering the SCORE 3 program July 22-26, 2013! SCORE 3 provides intensive rehabilitative programs for students in grades 7 to 10 with a focus on personal management, social competence, play and leisure that will encourage healthy, active lifestyles along with setting personal goals and planning for their successful futures.
To secure your spot, please complete the enclosed application package and return to CNIB Lake Joseph Centre for consideration. Space is limited for this life-changing program. Applicants will be considered on an individual basis. Once you have been accepted into this program, you will be sent a full registration package.
If you have any questions or would like to learn more, please call 1-877-748-4028.
We look forward to making memories with you.
Sincerely,
Lake Joe Staff and Volunteers
CNIB Lake Joseph Centre
R.R. #1 Mactier, ON P0C 1H0
T: 705-375-2630 or 1-877-748-4028
F: 705-375-2323
E:
2013 CNIB Lake Joe SCORE 3 Program Application Form
This form must be completed by all guests including guides and intervenors. Please print clearly. Forms will be returned if they are incomplete or illegible.
Name (first) (last)
Address
City Province Postal Code
Telephone (day) (evening)
Email Address:
Date of Birth: ______Age: ______Male £ Female £
Client £ Guide £
Grade Level (as of application): ____
Name of School: ______
CNIB Client Registration Number: ______
Vision Description/Diagnosis: ______
Communication Preference
Print Material
£ Braille
£ Large Print Font: ______
£ Other
Electronic Devices
£ ZoomText
£ JAWS
£ Other
CNIB Lake Joe SCORE 3 Program (five-day program=$400)
Ages 8-18
Monday, July 22, 2013 – Friday, July 26, 2013
Check-in 11 a.m. Check-out 1 p.m.
Transportation
Transportation to CNIB Lake Joseph Centre from Toronto (Yorkdale Mall) and Sudbury (Canadian Tire Plaza) is available. The transportation option is strongly recommended. It will provide participants with an opportunity to meet others prior to arriving at Lake Joe. Details to be confirmed, upon acceptance to the program.
£ Sudbury-Canadian Tire Plaza
£ Toronto-Yorkdale
£ Transportation not required
Declaration
I have read and understood the material relating to SCORE 3 and hereby declare that I meet all of the program requirements. I understand that to be considered for the program my completed application package including the Application form, Medical Information Form, personal essay, “My Three Wishes” and Applicant Profile Form must be received by CNIB by the specified deadline.
Signature of Applicant:
Date: ______
2013 CNIB Lake Joe SCORE 3 Program Applicant Profile Form
Please answer the following questions honestly. There is no right or wrong answer; we just want to get to know you a bit better.
1. What are four words you would use to describe yourself?
2. What would you say is your best characteristic?
3. Can you name three or four goals you would like to achieve?
4. How will you know if you have reached your goals?
5. Do you have any hobbies or special interests? If yes, what are they?
6. What would you like to learn while you are at SCORE 3?
7. What is the best way for you to learn?
8. Have you been camping before? If yes, describe your experience.
9. Are there any physical activities you currently participate in?
10. Do you travel independently? Please indicate if you use any travel devices.
11. Do you have any special medical or dietary needs or allergies?
12. How did you find out about the SCORE 3 program?
Payment Information
Please indicate the method of payment: Do Not Send Cash
Cheque £ Money Order £ Credit Card £
NSF Cheques will result in a $35 fee per payment.
I hereby authorize CNIB to charge the credit card listed below.
Amount $ ______Name of Cardholder: ______
(Please print)
Credit Card Number: ______
Expiry Date: / ______
Month Year
3 Digit Security Code: ______
Type of Credit Card (please check one):
VISA AMEX M/C ______
______
Signature of Cardholder Date
Please send completed CNIB Lake Joe SCORE 3 Program Application Package to:
CNIB Lake Joseph Centre
RR #1 MacTier, ON P0C 1H0
P: 1-705 375 2630 or 1-877-748-4028
F: 1-705-375-2323
E: