Camp Registration

Rainbow Day Camp 2023

"*" indicates required fields

YOUTH PARTICIPATE INFORMATION:

Youth First and Last Name*

Birth Date (mm/dd/yyyy)*

MM slash DD slash YYYY

Please select t-shirt size:*

Youth Small

Youth Medium

Youth Large

Youth X-Large

Adult Small

Adult Medium

Adult Large

Adult X-Large

Student's School*

Grade completed Spring 2023*

Teacher of the Visually Impaired (TVI) or O&M Specialist

First Last

TVI / O&M Phone

TVI / O&M Email

Age when vision impairment was first diagnosed?

Diagnosis or cause of vision impairment (if known):

Visual acuity and field of vision?

Please list all medical restrictions (including seizures) that require special modification with physical activity, including risk of retinal detachment:

List any allergies and dietary restrictions:

List all medications athlete is currently taking: (Camp staff will not be responsible regarding administering or reminding youth to take any medications)

YOUTH INTERESTS AND SKILL LEVELS:

Describe youth's current sports participation at school, clubs, recreation, etc.:

No experience is necessary.

What goals do you want to achieve at this camp?

PARENT/GUARDIAN INFORMATION:

Please list information for parent/guardian with whom the athlete currently resides with.

Parent First and Last Name*

Relationship to youth:*

Preferred Phone:*

Email:*

Preferred address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Consent to Participate:*

I understand there is risk of injury in any sport activity and grant permission for participation.

Medical Consent:*

I agree that minor medical needs for my child can be addressed by a staff person.

Photographic Release

I grant permission to use photographs and video taken of my minor child at the Rainbow Camp.

Parent/Guardian Signature:*

Date

MM slash DD slash YYYY

Names of all individuals who have permission to pick-up youth at camp.

EMERGENCY CONTACT:

If parent/guardian cannot be reached, in case of emergency, contact:

1st Contact Name:*

First Last

Relationship to youth:*

Preferred Phone Number:*

2nd Contact Name:*

First Last

Preferred Phone Number:*