Vision Academy Application

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Vision Academy Application

    Vision Academy Director: Lana Little
    Phone: 423-298-8991
    Email: Lana_Little@SignalCenters.org


    Please check which date(s) you are applying for:

    Participant Info

    Sex
    Do you give permission for Camp Signal Staff to discuss your child’s needs/interests with current teacher?

    (Parent's Initials)
    At school, does your child require a one-on-one assistant?
    Participant's T-shirt Size

    Parent/Guardian Info

    Mother

    Phone Type
    Phone Type
    Do you live in the Chattanooga city limits?

    Father

    Phone Type
    Phone Type
    Do you live in the Chattanooga city limits?

    Emergency Info

    Authorized to pick up?
    Authorized to pick up?

    Does the Participant?

    Have a behavior plan? (If Yes, please provide a copy.)
    Run away or is he/she a “runner”?
    Exhibit self-injurious behaviors?
    Wear glasses/contact lenses?
    Use a wheelchair?
    Crutches?
    Walker?
    Is the participant verbal?
    Use a communication device?
    Have emotional upsets?
    Does he/she have trouble communicating wants and needs?

    Health

    Does the participant have allergic reactions, including allergies to food or environmental?
    Please list ALL oral medications the participant takes, including OTC medicines. Bring all oral medications to camp in original containers with the participant’s name, dosage, and administration times. Medications must be given to the Camp Nurse or Staff by a parent or guardian. DO NOT ALLOW CHILDREN TO BRING MEDICATIONS. Attach additional paper, if necessary. Please make every effort to administer medications to your child prior to daily arrival at camp.
    Medication Name Total Dosage per Administration Total # of Pills per Administration Special Instructions Specific Times to Administer (ex. 9am, 2:30pm, etc.) To be Given During Camp Hours?
    Is there is any medical information the nurse needs to know about your child that is not listed on the application or in the health checklist (requires tube feedings, asthma that is typically exercised induced, has a g tube that is not being used, requires thick it for swallowing liquids, etc.)?
    YesNo
    Typical camp activities include dancing, sports, games, cooking, arts and crafts, playground activities, water days and more. Please describe or attach any instructions or precautions that should be taken during routine camp activities.
    Please list any camp activities in which the participant may NOT participate.
    It is agreed that Signal Centers assumes no responsibility for the participant’s personal property and is released from liability in connection with camping activities and medication administration, except as covered by the participant’s insurance. I understand my participant will be outside participating in various recreational activities.

    Release Form

    Permission is hereby granted for official representatives of Signal Centers and the business or individuals it designates to photograph my child, while participating in the 2021 Camps at Signal Centers. These photos will be used for the sole purpose of promoting, reporting, or publicizing the work and programs of Signal Centers. Such promotion may include the use of my participant’s name and picture in newspaper or other print media/promotions, DVDs, television news, and/or the Agency’s website. I also give my permission for observations of my child to be conducted and research and statistical data collected, so long as confidentiality of information is maintained.

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