Camp SIGN 2019 Camper Application Survey

1.Camper Last Name:(Required.)

2.Camper First Name:(Required.)

3.Camper Birth Date (MM/DD/YY):(Required.)

4.Age at Camp Date:(Required.)

5.School:(Required.)

6.Grade in 2019-2020 School Year:(Required.)

7.Gender:(Required.)

8.Race/Ethnicity:

10.Status of Hearing Loss:(Required.)

Deaf

Hard of Hearing

Other (please specify)

11.Camper's Method of Communication(Required.)

American Sign Language (ASL)

Signed Exact English (SEE)

Oral English

Other (please specify)

12.Parent or Guardian Information(Required.)

Parent

Grandparent

Guardian

Other (please specify)

13.Parent/Guardian Last Name:(Required.)

14.Parent/Guardian First Name(Required.)

15.Parent Contact Information:(Required.)

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Cell Phone:

Email Address:

16.Person to Contact in Case of Emergency:(Required.)

Emergency Contact Name:

Relationship:

Phone Number:

17.Behavioral Information: To better care for your child, please provide any information about their behavior or physical, mental, emotional, and social health that you think is important, or that may affect the camper's experience at Camp SIGN (i.e. attention deficit, sleep disturbances, shyness, etc.) Use the space below or call (512) 982-1709 (V/VP). Note: Any camper who becomes a continual problem at the camp site will be sent home.(Required.)

18.Income Reporting: List the average monthly income for each member in the household including children. Report gross income (amount before taxes, insurance, or deductions). You may choose not to provide the income information. If you do not provide income information, you must pay the full camp fee plus the application fee for your child. The amount due will be listed in the pre-acceptance letter. *If any member of the household is in the Supplemental Nutrition Assistance Program (SNAP) or received Temporary Aid to Needy Families (TANF), list his or her case number as well as the Social Security Number.

First Name, Last Name, *Social Security Number, Monthly Income:

If you do not wish to list the income information and agree to pay the full camp fee for this camper, enter your initials here:

19.By initialing next to each line below, I affirm that:(Required.)

I am providing true and correct information regarding my child or foster child;

I am applying to Camp SIGN for my child or foster child. I am submitting a non-refundable application fee of $35.00. I understand that I will be charged and held responsible for any fees incurred by checks submitted with insufficient funds;

I agree to release and hold harmless ODHHS Camp SIGN from any damages arising out of personal injury or sickness caused by any accident occurring on or off camp premises;

I give permission to ODHHS Camp Sign officials to provide any and all medical attention to my child in the event of injury and sickness;

I give permission for ODHHS Camp SIGN to photograph, use, and release photographs of my child for the purpose of publicizing and promoting Camp SIGN;

I understand that complete cooperation is expected from my child or foster child; and

I understand that I am responsible for transportation to and from camp for my child or foster child.

Parent or Guardian Full Name:

Today's Date (MM/DD/YY)

Camp SIGN 2019 Camper Application

Camp SIGN Application for Campers