Camp Independence Aplication

General Information

Campers must be between the ages of 12 and 16.

OBJECTIVES: To discover undeveloped potential, increase self-confidence, improve mental and physical vigor, and develop an appreciation for the campers own abilities and independence.

ELIGIBILITY: Legally blind persons age 12 to 16 are eligible on a nondiscriminatory basis. Campers with multiple disabilities may not be eligible.

REASON FOR DISMISSAL AND REJECTION: The Association of Blind Citizens has the right to reject or send a camper home, at the campers or caregivers expense, for the following reasons:

Falsifying the application
Engaging in illegal or prohibited activities
Not cooperating with the camp staff.
Recording false medical and/or mental condition

ARRIVAL AND DEPARTURE: Campers will be notified of arrival and departure times upon approval of their application.

NOT ALLOWED AT CAMP: No smoking, alcoholic drinks, drugs, firearms, or explosives are allowed at camp. Sexual activity is not allowed at camp.

A counselor is one to every three or four campers. A nurse is on duty 24/7.

ACTIVITIES: The activities will vary based on age and skill levels in accordance with the theme of the camp. Consult camp announcement for details.

NOTICE OF POSSIBLE CHANGES: Association of Blind Citizens, Inc. plans far in advance for its camps with the full intention of holding the camp as scheduled. It may become necessary, however, to reschedule, relocate, or cancel and the Association of Blind Citizens, Inc. assumes no financial liability for such changes. To confirm a camp date or location, please call the organizations office at 781-961-1023

ABC SUMMER CAMP APPLICATION

Camp Application

Camper Information

Campers Name

Name camper goes by if different from first name

Mailing Address

Mailing Address

Mailing Address

Mailing Address

City
City

State/Province
State/Province

Zip/Postal
Zip/Postal

Country
Country

Phone

Cell Phone

Legally blind: Central visual acuity that does not exceed 20/200 in the better eye with correcting lenses; field of vision no greater than 20 degrees in its widest angle (visual acuity of 20/200 means that a person can see at a distance of 20 feet what one with normal sight can see at 200 feet.)

Please select:

Legally Blind

Totally Blind

Gender

Male

Female

OtherOther

Birthdate

Age

In emergency, notify Name:

Emergency Contact Phone

Emergency Contact Cell Phone

Camper Personal and Health History

IMPORTANT Please notify the camp if the camper is exposed to any communicable disease during the three weeks prior to camp attendance. Not recording true medical and/or mental condition is reason for dismissal or rejection.

Visual Acuity

Uncorrected Left 20/ :

Uncorrected Right 20/ :

Corrected Left 20/ :

Corrected Right 20/ :

If your eyes are better than 20/200, why are you considered legally blind?

Health History

Has your child received a vaccine for Covid 19?

yes

no

(Check and give approximate dates & causes.)

Asthma

Heart Trouble

Kidney Trouble

Athletes Foot

Diabetes

Seizures

yes

no

if yes, date & cause of last one

Chronic or recurring illness

yes

no

if yes, please explain here

Operations (with dates)

Serious Injuries (with dates)

Bedwetting: Bring Pull-ups/Depends/ or equivalent for the entire weekend

Allergies

Insect Stings

Penicillin

Other (including medication or food allergy)Other (including medication or food allergy)

Mental Disabilities

Physical Disabilities

Please provide the child's shoe size

Restrictions

Association of Blind Citizens is NOT staffed to care for campers with mental and/or physical problems that require professional staff. Campers must be able to walk on their own and care for personal needs. Children with multiple disabilities may not be eligible due to availability of qualified volunteer staff.

Persons who cannot control their bowels should not attend camp.

Assistance level

Camper can perform daily hygiene activities unassisted (shower, dress, hair, etc.)

Camper can perform daily personal activities unassisted (eating, restroom, etc.)

Reason camper cannot perform activities unassisted

Please attach additional sheets if necessary. File Upload

Maximum file size: 268.44MB

Drop-Off / Pick-Up Authorization

The arrival and departure of the children to and from the designated pick up/drop off location for ABC
Tech Camp is the responsibility of the parent/guardian.

Name of Parent or Guardian

Please identify whom you authorize to drop-off/pick-up your child. We will not allow a child to leave with anyone not indicated below.

Name / Relationship of Authorized Person

Name / Relationship of Authorized Person

Name / Relationship of Authorized Person

I understand that only the above mentioned persons will be permitted to drop-off/pick-up my child at the ABC Camp.

In the case of unusual circumstances, I will call the Camp Director and notify him/her of the change and send a signed note with the newly designated person when they come to pick up my child.

Insurance Information

Name of Insurance Company

Insurance ID#

Name of Insured

Relationship to Camper

Please provide a copy of the medical insurance card (both sides).

Maximum file size: 268.44MB

MEDICAL EXAM AND PHYSICIAN STATEMENT

MEDICAL EXAMINATION (Required exam within past year)

This needs to be completed by camper’s primary care licensed physician or nurse. This examination should be performed not more than 12 months before arrival at camp for determining fitness to engage in strenuous activities.

Please Download this PDF for the Camper's Physician to complete and sign. Please send the signed and completed form to president@blindcitizens.org.

DOWNLOAD PDF

GENERAL INFORMATION ABOUT THE CAMPER

What are the Camper’s favorite foods?

Does the Camper have any dietary restrictions? If so, please describe.

What are the Camper’s favorite movies?

What are the camper’s favorite board games?

What is the Camper’s favorite type of music or favorite artist?

Does the camper play any musical instrument?

What crafts has the camper participated in and what is their favorite?

Does the camper enjoy reading during quiet time and what type of book. For example: mystery, science fiction, fantasy?

Format

Braille

Large Print

Audio

Other quiet time activities the camper enjoys are

Does the camper know how to swim?

yes

no

Has the camper had any computer training?

yes

no

If so, using which program for accessibility (i.e. JAWS, Zoom Text, etc.)

Does the camper use a white cane for travelling independently?

yes

no

Please read carefully and sign below. IT IS MANDATORY THAT THIS BE SIGNED. Your application will be returned if it is NOT signed.

I release the Association of Blind Citizens, the camp, its management and ownership from liability in case of accident or illness and do further indemnify and hold harmless such entities and persons from such claim.

The Association of Blind Citizens reserves the right to determine eligibility and acceptance of each participant to this program.

In case of a medical emergency, I hereby give permission to the physician selected by the camp director or healthcare personnel to secure proper treatment and/or to hospitalize as deemed necessary.

I understand that campers may be photographed videographed, and/or interviewed for use in news media, publications, or promotionals. I consent for the Association of Blind Citizens, Inc. to use all photographs, quotes, and recordings.

Be sure that applicable fees are enclosed with the application. Consult specific camp announcement for details.

A primary care medical person has signed the medical information

All information is correct to the best of my knowledge

I agree to cooperate with the camp staff

I agree not to engage in illegal or prohibited activities.

I understand and agree to abide by the restrictions placed on my camp activities

I understand that smoking and Use of illegal drugs, alcohol, tobacco products, firearms, explosives and sexual promiscuity are not permitted at camp.

Name of Person Filling out this form

Signature

Clear

(All campers under 18 years old must have parent’s or guardian’s signature.)

Date

I am the

Parent

Legal Guardian

Caregiver

If you are human, leave this field blank.

Join Us in Making a Difference
Your support can help transform lives. Join us in empowering individuals with visual impairments by volunteering, donating, or participating in our programs. Together, we can create a more inclusive community.

Support Us