Vision Camp Application for Young Adults

Home / Vision Camp Application for Young Adults

    Vision Camp Application for Young Adults and Seniors

    Participant Info

    Participant's T-shirt Size

    Emergency Info

    Does the Participant?

    Have allergic reactions,including allergies to food or environmental?

    Wear glasses/contact lenses?

    Use a wheelchair?



    Is the participant verbal?

    Use a communication device?

    Have emotional upsets?

    Have physical limitations

    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?

    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.