Registration Form – Summer Camp

Rainbow Day Camp

For students ages 5-18 with vision loss
July 18 – July 21, 2022
8:30 am – 4:30 pm at The Albert & Ann Deshur JCC Camp in Fredonia
Cost: $40 per person
Register by Monday, June 27, 2022

*Youth must have a medically diagnosed visual impairment and be independent in areas of walking, dressing, toileting and eating to participate in this camp.

Summer Youth Camp 2022

"*" indicates required fields

YOUTH PARTICIPATE INFORMATION:

MM slash DD slash YYYY
Please select t-shirt size:*
Teacher of the Visually Impaired (TVI) or O&M Specialist

YOUTH INTERESTS AND SKILL LEVELS:

No experience is necessary.

PARENT/GUARDIAN INFORMATION:

Please list information for parent/guardian with whom the athlete currently resides with.
Preferred address:*
Consent to Participate:*
Medical Consent:*
Photographic Release
MM slash DD slash YYYY

EMERGENCY CONTACT:

If parent/guardian cannot be reached, in case of emergency, contact:
1st Contact Name:*
2nd Contact Name:*

The cost for camp is $40 per youth.  You will receive a link with your registration confirmation to make an online payment.  Please contact Emily Zajork, 414-615-0179 or ezajork@vision-forward.org, with any questions.