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 PhoneTVI / 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:*