DYLC Application

CAMPER'S APPLICATION

Name*

First Middle Last

Preferred Name

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Age at Start of Session*

Gender*

Male
Female
Non-Binary

Preferred Pronoun*

T-Shirt Size*

Home Phone/VideoPhone*

Email Address*

How did you learn about us?

PARENT/GUARDIAN INFORMATION

Name of Parent(s)/Guardian*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone/VideoPhone (Day Phone)

Home Phone/VideoPhone (Evening Phone)

Fax # (Home or Office)

Other Important Phone #

Email Address*

EMERGENCY CONTACT (please indicate adults whom we should contact in an emergency, if we cannot reach you)

Name*

First Last

Relationship*

Day Phone/VP*

Evening Phone/VP*

Text Number*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

GENERAL INFORMATION

Has the applicant ever attended camp before?*

Yes
No

If Yes, Name of Camp(s)

Please describe the applicant's swimming ability*

Describe the applicant's school/education program*

What are some of the applicant's interests and hobbies?*

Describe any additional assistance required (NOTE: campground is not wheelchair accessible):*

Is a 1 to 6 ratio ok or will camper require more supervision?*

Does the camper have any toileting needs i.e. bed wetting or daytime requirements?*

Yes
No

If Yes, please explain*

COMMUNICATION INFORMATION

Does the applicant use hearing aid(s)?*

Yes
No

Special instruction for the use of hearing aid(s) or other assistive device(s)*

Does your child use sign language? (NOTE: Sign Language is the main mode of communication at camp)*

Yes
No

Indicate the Applicant's communication mode(s) (Please check all that apply)*

ASL
Sign with Speech
Spoken English
LSM
Other

If Other, please document the communication mode

Does your child have a cochlear implant?*

Yes
No

If Yes, what restrictions does your child have in camp activities?*

SIGNATURE REQUIREMENTS

Indemnification (Waiver's) Agreement*

I/We agree to indemnify, hold harmless, and defend DCS Literacy Camp and their respective employees, agents, and representatives from and against any and all liabilities, claims or demands which may be asserted against any or all of them in connection with our applicant’s participation in DCS Literacy Camp. This includes holding DCS Literacy Camp harmless for any injury which may occur to our applicant while traveling to the DCS Literacy Camp’s facility, or while returning from the DCS Literacy Camp to go home.

Behavioral Expectations*

I/We have read this with/to my child and we understand and agree to these conditions. If my child is having difficulty adhering to the appropriate behavior expectations, they will be encourage to modify their behavior(s). If in appropriate behavior(s) continues, however, a camper may have to agree to a behavioral contract and, ultimately be asked to return home. By fulfilling these camp expectations, we foresee a cooperative and fun week.

Authorization, Waiver and Model Release*

I hereby grant Deaf Community Services of San Diego, Inc., and its staff, filmmakers, photographers and representatives full permission to showcase me and/or my child in performance and to copyright, use and publish video logs, photographic or video prints or other reproductions from all negatives, videos, or films made of me, my child or children at any place or time, and to make of me at any place or time, and to make and use photographic prints or other reproductions of all or part of said negatives or films, either in conjunction with or without using my name, and to make any changes or additions thereto or both for publication, advertising or display, whether in connection with a fictitious name, testimonial copy or otherwise. I hereby release Deaf Community Services of San Diego, Inc., and its photographers and representatives from any and all claims, damages or causes of action arising, directly or indirectly, in connection with the performance and use of the material referred to above. I also understand and agree that I will receive no money or other payment for giving this permission. I understand that I have the right to request for my photo(s) to be removed at any time. By checking the box, I knowledge that I have read and understand the meaning of this Media Release Form.

ALL CAMPERS AND PARENTS WILL NEED TO SIGN THE BULLYING POLICY FOR DCS LITERACY CAMP. DCS LITERACY CAMP HAS A ZERO TOLERANCE FOR BULLYING. ANY CAMPER WHO HAS NOT HAD A PHYSICAL IN THE PAST 24 MONTHS PRIOR TO CAMP WILL NEED TO HAVE A PHYSICAL WITH THE MEDICAL FORM SIGNED BY THE DOCTOR.

PARENT(S)/GUARDIAN(S)' COMMENTS ON APPLICANT (Comment on applicant’s communication, social, and group skills. Please indicate any area of concern so the camp can accommodate the applicant/camper’s needs.)*

SCHOOL AUTHORIZATION*

I/We give permission for my/our child’s school to share information on character/behavior reference with DCS Literacy Camp.

AUTHORIZATION FOR EMERGENCY MEDICAL CARE (please email medical insurance card to nroquemore@dcsofsd.org)*

I/We hereby give permission to DCS Literacy Camp to call a doctor or emergency medical service and for the doctor, hospital, or medical service to provide emergency medical or surgical care for my/our child (name)_________________________________________ , should an emergency arise. It is understood that DCS Literacy Camp will make a conscientious effort to locate parents, and/or any emergency contact listed on this form, before any action is taken. I/We will accept the expense of medical or surgical treatment.

Camper's Application

CAMPER'S APPLICATION

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT (please indicate adults whom we should contact in an emergency, if we cannot reach you)

GENERAL INFORMATION

COMMUNICATION INFORMATION

SIGNATURE REQUIREMENTS

ALL CAMPERS AND PARENTS WILL NEED TO SIGN THE BULLYING POLICY FOR DCS LITERACY CAMP. DCS LITERACY CAMP HAS A ZERO TOLERANCE FOR BULLYING. ANY CAMPER WHO HAS NOT HAD A PHYSICAL IN THE PAST 24 MONTHS PRIOR TO CAMP WILL NEED TO HAVE A PHYSICAL WITH THE MEDICAL FORM SIGNED BY THE DOCTOR.

Welcome back,