Class:  Olympic Games 2012 (Please select a camp from the drop down list)

Please select the recreational activities you would like to do each day:

Monday: All Campers will be expected to participate in Yoga and Bowling

Tuesday: Golf Aquatic Park

Wednesday: Rock Climbing Tandem Cycling

Thursday: Rowing Hiking

Swimming Level: Please select appropriate level
Do not know how to swim and do not feel comfortable in the water Am comfortable in the water but shallow water swimming only Can swim in shallow and deep water comfortably and can pass a deep end swim test I can swim competitive strokes

Name:              Gender:  Male Female

Address:      

City:               State:   Zip:

Date of Birth:     Age:

Home Phone (Including Area Code): 

Parent or Legal Guardian:

Work Phone:   Cell Phone:

Emergency Contact (Different than above):     

Emergency Telephone (Including Area Code): 

Educational Information

Grade Level Entering for September 2012:

Reading Medium (Braille, Large Print, Regular Print, Auditory):

Reading Grade Level:

School District:         

Vision Teacher:        

Does this student use a long cane for travel?  Yes No

Does this student have a mobility instructor?  Yes No   Name:    

Does this student use low vision aides?          Yes No   Describe:

Medical Information

Primary Physician:

Telephone Number (Including Area Code):  

Policy Name/Group Number:

Telephone Number (Including Area Code): 

Type of Visual Impairment:

Acuity:

Does the Student Have any Physical Impairment other than the Visual Impairment? Yes No  

    Describe:

Other Medical Conditions (ie asthma, endocrine disorders, mental health concerns, VP Shunt):

Immunizations (Enter dates)

Current Medications:

NOTE: MEDICATIONS MUST BE IN THE ORIGINAL CONTAINER AND PRESCRIBED BY AN MD, PA OR NP.

Permission to administer over the counter medication during attendance? (I.E. Tylenol, cough syrup) Yes No

Please list any restriction regarding over the counter medication:

Allergies (medication/food):

Special Diet (Include Physician's order):

Any history of seizures? If yes, please describe

Permissions and Releases

My Child will Live on Campus during the time of the course. Yes No

I authorize WSSB personnel to provide emergency medical care for my child in the case of illness or accident in the event I am unable to be contacted. Yes No

I agree to accept responsibility for payment of any medical care for my child that may be necessary during the week. Yes No

I understand that my child will be subject to the following rules:
 1.    Students will be allowed off campus only when accompanied by an adult staff member. NO Exceptions.
 2.    No tobacco products - no smoking - no knives - no weapons - no exceptions.
 3.    Any student found with alcohol, controlled substances or drug paraphernalia will be sent home immediately at the parent's
        expense.
 4.    All students will participate in leisure and recreational activities as planned.
 5.    Students will follow the directions of the staff members.

Parent/Guardian Signature:

Email Address: