SPORTS CAMP Application 2024

Participant Application Process

Dear Campers,
Thank you for your interest in the Lighthouse for the Blind's 2024 Sports Camp!!

Please review the Eligibility Requirements to participate:
* The camper must be between the ages of 12 and 18 as of June 1, 2024.
* The camper must have a medical and educational diagnosis of a visual impairment.

*The camper must be able to participate in contact sports.

* The camper must be able to independently shower, get dressed, toilet, and perform all self-hygiene.

* The camper must have family available to pick them up from the camp should illness or injury arise.

Camp Activities:

Ice Hockey

Beepball

Soccer

Goalball

Water Park

Rock Climbing

Yoga

Application Process: Only 16 campers will be accepted to participate, so make sure your application is completed on time for consideration! The application deadline is May 1, 2024. We will notify you via email in mid-May to let you know if your camper has been accepted.

The Sports Camp Staff keep all medications for distribution but all campers must be able to administer their own medication.

Please call Angie Yorke if you have questions about eligibility or the application!

Angie Yorke, Blind Community Enrichment Coordinator

314-423-4333 x132

ayorke@lhbindustries.com

Question Title

* 1. Camper Information:

Last Name:

First Name:

Street Address

City:

State Abbreviation:

Zip Code:

Date of Birth:

Age as of June 1, 2024

Biological Sex (male/female):

Grade as of August 1, 2024 (if graduated, write "graduated"):

T-Shirt Size (please specify "youth" or "adult" and the size):

Question Title

* 2. Parent/Guardian Information

Parent/Guardian 1 Name (if none, write "none"):

Parent/Guardian 1 Email (if none, write "none"):

Parent/Guardian 1 Mobile Phone (if none, write "none"):

Parent Guardian 2 Name (if none, write "none"):

Parent/Guardian 2 Email(if none, write "none"):

Parent/Guardian 2 Mobile Phone (if none, write "none"):

Emergency Contact Name:

Emergency Contact Relationship:

Emergency Contact Mobile Phone:

Question Title

* 3. Additional Camper Information:

	Yes	No
Has the camper previously participated in LHB's Sports Camp or another similar residential program for individuals with visual impairments?	Has the camper previously participated in LHB's Sports Camp or another similar residential program for individuals with visual impairments? Yes	Has the camper previously participated in LHB's Sports Camp or another similar residential program for individuals with visual impairments? No
Has the camper ever spent the night away from home?	Has the camper ever spent the night away from home? Yes	Has the camper ever spent the night away from home? No
Does the camper attend the Missouri School for the Blind or another State School for the Blind and Visually Impaired?	Does the camper attend the Missouri School for the Blind or another State School for the Blind and Visually Impaired? Yes	Does the camper attend the Missouri School for the Blind or another State School for the Blind and Visually Impaired? No
Does the camper utilize a long, white cane for mobility?	Does the camper utilize a long, white cane for mobility? Yes	Does the camper utilize a long, white cane for mobility? No
Does the camper have a shunt or another implanted device?	Does the camper have a shunt or another implanted device? Yes	Does the camper have a shunt or another implanted device? No
Does the camper use an alternative form of communication?	Does the camper use an alternative form of communication? Yes	Does the camper use an alternative form of communication? No
Does the camper have physical limitations for participating in activities/sports? If "yes," please describe in the comment section below.	Does the camper have physical limitations for participating in activities/sports? If "yes," please describe in the comment section below. Yes	Does the camper have physical limitations for participating in activities/sports? If "yes," please describe in the comment section below. No

Other (please describe physical limitations):

Question Title

* 4. Sports Camp will be going swimming and to a waterpark with facility lifeguards present. Please rate the camper's skill level in the water and/or provide additional comments below.

Non-Swimmer (will not or cannot get in the water)

Explorer (may sit in shallow end; will always hold the wall; learning to float; does not tread water; hesitant to submerge)

Fundamental Swimmer (can float; can tread water; will jump into the water; does not know strokes)

In-Development (can float; can tread water; swims with arms and legs - learning freestyle or breast; retrieves objects under water)

Proficient (floats; treads; flips; capable of long submersion; knows multiple strokes; fluent/fitness swimmer)

Question Title

* 5. Participant Medical Information

Visual Diagnosis:

Visual Acuity (if "none," write "none"):

Visual Field Deficit (degree restriction or range of vision present, if no deficits, write "none"):

Medical Diagnoses (Cerebral Palsy; Hearing Impairment; Asthma; ADHD; Austism Spectrum; Emotional Disturbance, etc):

List prescription medications:

Do you require a nurse or another person to administer your medication (yes or no):

Do any of your medications require injection (yes/no):

List allergies in the outdoors (pollen, bees, etc.), if none, write "none":

List food allergies, if none, write "none":

List dietary restrictions, if none, write "none":

Question Title

* 6. Please tell us any other important details about your camper that you think we need to know when considering their application.

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* 7. CONSENT FOR RELEASE OF INFORMATION:
My electronic signature below hereby authorizes and gives permission to the Lighthouse for the Blind – St. Louis to obtain and/or provide the camper's information to prior or current school district(s) and related professionals, optometrist/ophthalmologist, State Rehabilitation Services for the Blind, or any other educational institutions for programming and collaboration regarding the applicant/participant listed below.

Camper's Name:

Electronic Signature (parent/guardian signature required if the camper is a minor under age 18):

Date:

Question Title

* 8. PUBLICITY RELEASE CONSENT:
My electronic signature below hereby authorizes and gives permission for the camper's name, photograph, video and/or other identifying information (such as age, eye condition, etc.) to be used by the Lighthouse for the Blind – St. Louis for publicity / collaborative / training purposes. I understand such uses may include brochures, newsletters, website entries, press releases, or written stories without payment or any other compensation. I further understand some uses may be for information and material sent to other organizations/companies (newspapers, television, radio, conference presentations, etc.) and that the materials will become the property of the Lighthouse for the Blind – St. Louis and will not be returned.

Camper's Name:

Electronic Signature (parent/guardian signature required if the camper is a minor under age 18):

Date:

Question Title

* 9. GENERAL LIABILITY, TRANSPORTATION & MEDICAL TREATMENT WAIVER

General Liability Waiver:

I, being the parent/legal guardian of the applicant do hereby consent
to his/her participation in voluntary functions sponsored and/or organized by the Lighthouse for the Blind – St. Louis. I understand that he/she is responsible for his/her behavior. I do hereby waive and release the Lighthouse for the Blind – St. Louis, their service partners (including schools) and/or sponsors of any project, event, or function, from all claims and liabilities, of any kind whatsoever, arising from, whether directly or indirectly, my child/ward’s participation in Lighthouse for the Blind – St. Louis, and the or functions.

Transportation Liability Waiver:

I do hereby consent to The Lighthouse for the Blind – St. Louis providing transportation (in commercially procured and private vehicles) for my child/ward if necessary. I do hereby waive and release the Lighthouse for the Blind – St. Louis, their service partners and/or sponsors of any project or function, from all claims and liabilities, of any kind whatsoever, arising from, whether directly or indirectly, my child/ward’s involvement in transportation services provided by the Lighthouse for theBlind – St. Louis.

Release to Seek Medical Treatment*

In the event of a medical emergency, I do hereby consent to the Lighthouse for the Blind – St. Louis releasing my child/ward to the nearest, most appropriate medical professional available. I understand that the Lighthouse for the Blind – St. Louis will notify me of such an event immediately after they have sought proper medical treatment for my child/ward.

Camper's Name:

Electronic Signature (parent/guardian signature required if the camper is a minor under age 18):

Date: