Rainbow Day Camp

Mark your summer calendars!

Vision Forward in collaboration with the JCC present Rainbow Day Camp 2024! Children and youth with vision loss will have an opportunity to participate in a variety of adaptive sports and activities and make connections with other youth with vision loss at the beautiful 110-acre campsite Fredonia.

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2024 Rainbow Day Camp

"*" 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 2024*

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:*