Complete the online registration form below or print and mail in a paper copy from HERE ! eligibility criteria before registering!
Camper Information:
Last Name:
First Name:
Address:
County:
Phone:
Age:
Gender:
Male
Female
Previous Experience:
Parent/Guardian Information:
Last Name:
First Name:
Relationship to the Camper:
Parent
Grandparent
Guardian
Roommate Request (if any):
Camper Information Continued:
What is your vision impairment:
Decription of Visual Impairment:
What is your vision impairment classification?
B1 (Blind)
B2 (Less than 5% vision or no less than 20/600)
B3 (Less than 20% vision or no less than 20/200)
B4 (More than 20% vision or no less than 20/70)
Describe any additional/secondary disabilities:
Independent?:
Yes
No
Can feed him/herself?
Yes
No
Can dress him/herself?
Yes
No
Can toilet him/herself?
Yes
No
Can walk without assistance?
Yes
No
Name and contact information of child's consultant/transition counselor from CBVH?
Who is your vision specialist?
Has the New York State Commission for the Blind agreed to fund your child this year?
Yes
No
Will your child need to be picked up at the train station or airport?
Yes
No
If yes, describe what will need to be done:
Medical Information:
The following is a list of over the counter medications used by our directors/camp nurses for minor discomfort. Medications will be administered according to package recommendation for dosage administration for the following: minor aches, fever, cramps, headaches, sprains, sinus congestion, diarrhea, sunburn, abrasions, stomach ache, indigestion, and cough.
Please check those medications you would NOT want your child to take:
NONE
Tylenol
Advil
Sudafed
Benadryl
Imodium
Pepto-Bismol
Tums
Cough Drops
Acknowledgement:
I have reviewed the above list of over the counter medications used at camp and give my permission for administration as per recommended dosage with the exceptions noted. I also understant the generic formula for these products may be used.
Medication Information:
Please list ALL medication your child is currently taking. PLEASE BE SPECIFIC!
Medication #1:
Medication #2:
Medication #3:
List any additional medicines with doses and information below:
Please answer the following questions:
Does your child have difficulty going from dark to light places?
Yes
No
Does your child have difficulty going from light to dark places?
Yes
No
Does your child have a good sense of peripheral vision?
Yes
No
Does your child have a good sense of central vision?
Yes
No
Does you child have tunnel vision?
Yes
No
We, the camper and the parent, accept the eligibility criteria and conditions and acknowledge that all the information provided above is our own. (Check both boxes below to accept.)
Parent Electronic Signature:
Camper Electronic Signature:
*** BOTH CAMPER & PARENT SIGNATURE NEED TO BE CHECKED BEFORE THIS FORM CAN BE SUBMITTED ***
