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Camp GDB Application

Included in this Application

Camper application (Page 1)
Camp GDB Transportation (Page 2)
Proof of Medical Insurance (Page 3)
Publicity Release and Release of Liability (Page 4)
Consent Form (Page 5)
Permission to Provide Emergency Care (Page 6)
e-Signature (Page 7)

Required Supporting Documents

An Essay “Why I want to attend Camp GDB” to be written by the applicant.
A current photo of the applicant
Copy of insurance card
Physician's Report (Download via the link below if you haven't already done so from our website)
Download Physician's Report

Camper Application

Parent or Guardian Information

Prefix

First Name (Required)

Middle Name

Last Name (Required)

Email (Required)

Address Information

Street Address (Required)

City (Required)

State (Required)

Country (Required)

Zip Code (Required)

Is this your mailing address as well? (Required)

Mailing Address

City

State

Country

Zip Code

Contact Information

Preferred Phone (Required)

Home Phone (area code first) (Required)

Work Phone (area code first) (Required)

Mobile Phone (area code first) (Required)

Other Phone (area code first) (Required)

Preferred method of correspondence (Required)

Applicant Information (Child's Information)

First Name (Required)

Middle Name

Last Name (Required)

Date of Birth MM/DD/YYYY (Required)

All applicants must be between the ages of 14 and 17 to apply.

Grade

Gender

Pronoun (optional)

Ethnicity (optional)

Primary Language Spoken

Application

Emergency Contacts:

#1 Emergency Contact Name (Required)

#1 Emergency Contact Phone (Required)

#1 Emergency Contact Relationship (Required)

#2 Emergency Contact Name

#2 Emergency Contact Phone

#2 Emergency Contact Relationship

Personal and Health Information:

Has the applicant attended Camp GDB before

If Yes what year(s)

Year applicant declared legally blind?

Cause of visual impairment?

If your cause of blindness is not in the list above, please describe.

If partially sighted, describe the applicant's functional vision:

Right eye:

Left eye:

Does the applicant have physical limitations such as neuropathy or problems with balance?

If yes please describe:

Does the applicant have any cognitive, emotional, behavioral or psychological limitations?

If yes please describe:

Does the applicant see a mental health professional for emotional or psychological limitations?

If yes, how long has the applicant been under their care?

Does the applicant have a seizure disorder?

If yes, date of last seizure

Does the applicant have hearing loss?

Left ear:

Right ear:

Does the applicant require assistance with their medications and/or medical condition?

If yes please describe:

Please describe how the applicant might react to the following:

Unexpected change:

Loud noises:

Not having a consistent routine:

Can the applicant participate in walks up to an hour in length?

Can the applicant swim independently in a pool of 3-foot depth?

Can the applicant swim independently in a pool of 6-foot depth?

Can the applicant swim independently without a flotation device?

Does the applicant have any food allergies?

If yes, please list specific foods

Is the applicant on a special diet?

If yes, please indicate any dietary restrictions/needs:

Is the applicant currently using a mobility aid?

Please indicate what kind of mobility aid currently using.

If other, please specify.

Has the applicant ever had an alcohol or substance abuse problem?

Has the applicant ever been convicted of a felony (Indictable offense)?

Is there anything else that would be helpful for us to know about the applicant? (please describe in detail)

Other

How does the applicant prefer to receive printed material?

Applicant’s T-shirt size (Shirts are unisex style):

How did the applicant hear about Camp GDB?

Supporting Documents

1) Essay written by the applicant titled “Why I want to attend Camp GDB"

2) A recent picture of the applicant

Please upload the essay here: (Required)

Please upload the picture of applicant here: (Required)

Acknowledgment

Camper's Name (Required)

Parent or Guardian Name (Required)

By checking YES, I acknowledge that the above information is true and that any falsified information may result in denial of participation.

Yes (Required)

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Camp GDB Transportation Form

Transportation Form

How will the applicant arrive to Hull Park Foundation
for Camp GDB.

Out of area, will be arriving by Plane (Guide Dogs for the Blind will provide transportation from the airport to the Hull Park Foundation.

Out of area, will be arriving by Plane but we will provide transportation to the Hull Park Foundation.

We live locally and will provide transportation to the Hull Park Foundation.

How will the applicant depart from Hull Park Foundation at the end of Camp GDB.

Out of area, will be departing by Plane (Guide Dogs for the Blind will provide transportation to the airport from the Hull Park Foundation.

Out of area, will be departing by Plane but we will provide transportation from the Hull Park Foundation to the airport.

We live locally and will provide transportation from the Hull Park Foundation.

Please provide the name and contact information of the person(s) who will be dropping off and/or picking up your child from the Hull Park Foundation.

Drop off (first day of camp at 2:00pm):

Name

Relationship to your child

Phone Number:

Pick up (last day of camp at 10:00am):

Name

Relationship to your child

Phone Number:

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Proof of Medical Insurance

Medical Insurance

Guide Dogs for the Blind requires that all campers are insured and can show proof of medical insurance. If your child is uninsured, we require that you purchase traveler’s insurance for the duration your child will be at camp, and we have provided two resources for this below.

Name of insured

Primary Care Physician

Physicions Number

Name of insurance carrier:

Membership Number:

Expiration date (if any):

Please include:

A copy of you child's medical insurance card below

Uninsured camper Resources:

Travel Guard

800-826-5248

www.travelguard.com

Word Nomads

www.worldnomads.com

Also, if you have a VIAS Credit Card it may offer travelers insurance at a reduced rate.

Supporting Documents

1) Please attach a copy of your child's medical insurance card or proof of their traveler's insurance

Please upload proof of insurance here: (Required)

Acknowledgment

By checking YES, I acknowledge that the above information is true and that any falsified information may result in denial of participation.

Yes (Required)

Page 4 of 7

Camp GDB Media, Promotion and Personal Information Release Form

Release of Liability Form

Publicity Release:

GUIDE DOGS FOR THE BLIND may wish to use various multimedia files (e.g., photography, audio/video recordings) and general information about participants in our programs for publicity and/or marketing purposes. These files may be used in any and all promotional media, including but not limited to: newsletters, brochures, website, blog, fundraising materials, social media channels, press coverage, promotional videos, public service announcements, etc. Also, please be advised that at GDB events (either on our campuses or hosted elsewhere), photography, audio/video recording, and live streaming may occur. By attending a GDB event, you consent to such recording media and its release, publication, exhibition, or reproduction. Thank you!

The Publicity Release options are as follows:
Full Permission For Publicity: The undersigned does hereby give permission to use their likeness for marketing or publicity purposes, or to otherwise promote GUIDE DOGS FOR THE BLIND to the public from the date signed and in perpetuity. Minors must have a parent or guardian’s signature.
Denial of Permission For Publicity: I do not want my likeness used for marketing or publicity purposes by GUIDE DOGS FOR THE BLIND.

Please Select One of the Publicity Release options (Required)

Release of Liabilty

In consideration of the undersigned being accepted as a student, and in further consideration of the training, use of the facilities, and other benefits the undersigned receives from Guide Dogs for the Blind, Inc. (“GDB”), the undersigned does hereby agree, among other things, that he or she shall hold harmless GUIDE DOGS, its directors, employees, officers, representatives, heirs, executors, administrators, agents and assigns from liability for any injury, damage, sickness and/or medical expense or eventuality that may occur or arise as a result of the undersigned’s training, attendance at the school and use of the facilities, except as a result of negligence on the part of said GDB, the undersigned does hereby release, indemnify and hold GDB free and harmless from any and all liability, claims, damages, losses or expenses, including counsel fees and costs, arising as a result of the undersigned’s training and/or attendance at the GDB school and use of the facilities.

The undersigned understands that a safe is provided by GDB for student’s valuables, and therefore will not hold said GDB liable for the loss of monies, jewelry, records and/or other personal articles of value that he or she may choose to retain in his or her possession.

By checking YES, I accept the terms to this release of liability

Yes (Required)

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Authorization for Use or Disclosure of Medical and Other Information

Consent Form

Please complete the following consent form. This form allows Guide Dogs for the Blind to contact your physician, Orientation & Mobility instructor and mental health professional (if applicable) for information that will help us complete your Camp GDB application. It is not necessary to bring this form to your providers. We will send them the necessary forms if you provide us with their complete mailing addresses. If you do not have a physician you see regularly, please leave that section blank and we will send the form directly to you to take to your doctor.

A. Explanation: This authorization for use or disclosure of medical or rehabilitation information is being requested from you to comply with the terms of the Confidentiality of Medical Information Act of 1981, California Civil Code Section 56, et seq.

B. Authorization: I hereby authorize the below listed providers, to furnish to Guide Dogs for the Blind, Inc. and its authorized representatives, any medical records, which include information pertaining to medical history, mental or physical condition, services rendered, and/or treatment for the purpose of applying for their summer camp program. This authorization extends to all information requested in the required Physician’s Report, the Mental Health Professional’s Report and the Orientation and Mobility Instructor Report.

I understand that authorizing the disclosure of my medical information is voluntary. I can refuse to sign this authorization. I further understand that I have the right to inspect and copy the information disclosed as a result of this authorization. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure, which may or may not be protected by federal or state confidentiality rules. If I have any questions about the disclosure or use of this information, I may contact the Admissions Manager at Guide Dogs for the Blind at 1 800 295 4050.

C. Uses: Guide Dogs may use the medical records and information authorized: to assist in the determination of eligibility for acceptance to Guide Dogs summer camp; to assist Guide Dogs in providing the camper with medical assistance during the camp program; and for any other legally permissible reason deemed necessary by Guide Dogs.

Access to medical and mental health records will be restricted to Guide Dogs’ staff involved in the application, assessment, selection, and care of campers. This group consists of: Nursing and outreach/Admissions staff. Members of the GDB IT staff will also have access to this information.

D. Duration: This authorization shall become effective immediately and shall remain in effect for two years after the date signed below.

E. Restrictions: I understand that Guide Dogs may not further use or disclose the medical information except as authorized herein unless another authorization is obtained from the applicant or unless such use or disclosure is specifically required or permitted by law.

F. Additional Copy: I further understand that I have a right to receive a copy of this authorization upon my request.

Authorized List of Providers and Their Mailing Addresses

Primary Physician (medical doctor)

(Please do not list your ophthalmologist or optometrist)

Name of Physician:

Name of Medical Center:

Street Address:

City, State Zip:

Phone Number:

Fax Number:

Email Address:

Mental Health Professional (if applicable)

Name of Counselor:

Name of Office:

Street Address:

City, State Zip:

Phone Number:

Fax Number:

Email Address:

Orientation and Mobility Specialist (COMS)

Name of Instructor:

Name of Agency:

Street Address:

City, State Zip:

Phone Number:

Fax Number:

Email Address:

Teacher of Students with Visual Impairments (TVI)

Name:

Name of School:

Street Address:

City, State Zip:

Phone Number:

Fax Number:

Email Address:

Supporting Documents

1) Please attach a copy of the Physicians Report here.

Please upload Physicians Report here: (Required)

Date: (Required)

Minor Applicant Name: (Required)

Name of Parent or Legal Guardian: (Required)

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Permission To Provide Necessary

Emergency Care

Permission to Provide Necessary Emergency Care:

I hereby give permission to Guide Dogs for the Blind, Inc., to provide routine health care and seek emergency medical treatment if indicated, and give permission to Guide Dogs for the Blind, Inc., staff to communicate with emergency personnel and physicians if necessary.

Applicant's Name (Required)

Parent/Guardian (Required)

Date: (Required)

Emergency Contact Phone Number (Required)

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e-Signature

Application Package e-Signature

I/We, the parent(s)/guardians(s) of,

[Child's Name] (Required)

acknowledge that I/we have read and understand the camp information, including the camp's policies, procedures, and program activities.

I/We understand that participation in camp activities involves inherent risks, and I/we assume these risks on behalf of my/our child.

I/we hereby give permission to Guide Dogs for the Blind, to provide routine health care and seek emergency medical treatment if indicated, and give permission to Guide Dogs for the Blind, staff to communicate with emergency personnel and physicians if necessary.

I/We have provided accurate and complete information on this application, including my/our child's medical history and any special needs. I/We agree to inform the camp immediately of any changes to this information.

Date (Required)

Parent or Guardian Name(Required)