DeafBlind Camp of Maryland 2013

SSP/Volunteer Application

General Information Last Name: First Name: Street Address: APT #: City: State: Zip Code: Home Phone: TTY VRS Voice Work Phone: TTY VRS Voice Cell Phone: TTY VRS Voice Email: Fax Number: I want the above contact information listed in the camp directory. Yes No Age: Male Female Check all that apply: Deaf Hard of Hearing Hearing Blind Low Vision Sighted Do you have any mobility problems? Please explain. How did you learn about the camp?

Experience Have you attended the DeafBlind Camp of Maryland before? Yes No

Please list the years you have attended:

Have you had experience as an SSP? Explain. Are you certified? List certifications. If certified, would you like to mentor students? If ASL is a second language, please list your highest level ASL course and any other deaf studies courses completed. Please rate your signing or interpreting skills:

	Beginning	Conversational	Fluent
ASL
PSE
English Sign
Tactile sign

Check here if do not have Sign Language skills. My dominant hand for tactile signing is: Right Hand Left Hand Name of camper/campers you prefer to be matched with: Name of camper/campers you prefer NOT to be matched with: In what way would you like to volunteer your talents? (Check all that apply) Platform Interpret SSP with DB Camper Driving or help with transportation Help with Arts and Crafts, Yoga, Swimming, Boating, Massage, Haircuts, Manicures, Makeup, etc. Please Explain: Are you traveling with a DB camper? Yes No

Whom?

Availability

When will you be at camp? Please be specific! If you are not staying full time, we must know which overnights and which meals so we can order and pay for your bed and your meals. Preference will be given to SSPs who can come the full week or half week (Sunday - Tues or Wed - Friday).

Will you attend the SSP training on Saturday, June 8, 2013? Yes No Do you need housing on Sat. night? Yes No When are you available for camp? Full time (I will stay at camp ALL week (arrive before 3 pm Sunday and leave after 11:00 a.m. on Friday) Part time (Specify the day(s) and time below and check your meals and overnight stays)

Day	Breakfast	Lunch	Dinner	Overnight
Sun
Mon
Tues
Wed
Thurs
Fri

Lodging and Food Please check here if you are a Vegetarian Do you have any dietary restrictions or food allergies? Is there anyone you wish to share your room with? Is there anyone you DO NOT wish to share your room with? Do you snore? Yes No Do you smoke? Yes No Do you want to rent linens for cost of $5? Yes No Will you be bringing a service animal with you to camp? Yes No Can you room with someone who has a service animal? Yes No

Medical and Emergency

In case of an emergency, whom should we contact?

Name: Relationship: Day time phone: Voice TTY VRS Evening Phone: Voice TTY VRS Check if you have any of the following: Diabetes Heart problems High Blood Pressure Recent Surgery

Type of surgery:

Allergies

Please list all allergies:

Describe any other health conditions: Do you take any medications: Yes No

Please list medication(s):

Doctor's name: Doctor's phone: Insurance Company (If none, write "none"): Insurance Policy Number: Date of Birth:

(Your medical information will be kept confidential)

Terms and Condition

Medical Release

In the event that my consent cannot be readily obtained, the camp nurse and/or camp staff are authorized to consent on my behalf for necessary medical treatment. In case of medical emergency, the camp nurse or camp staff is authorized to obtain treatment for me including medication, anesthesia or surgery.

I agree to indemnify and not hold liable West River Camp and Staff and/or the DeafBlind Camp of Maryland or the camp coordinators if injured during camp.

I accept

Permission for Photography:

I give permission for other camp participants to photograph and video graph me during camp.

I accept

By submitting, I agree that all info entered was done accurately & truthfully.