DEAFBLIND RETREAT DB PARTICIPANT APPLICATION
1. , ______
First name Last Name
2. ______
E-mail address
3. Apt # _____
Street Address
4. , , ,
City, State, Zip Code, Country
5. Primary Phone: () __- ___
Text VP TTY Voice
6. Secondary Phone: () _- _____
Text VP TTY Voice
7. Date of Birth / /19 Age___
8. Female Male Other
9. PLEASE INCLUDE A PICTURE OF YOURSELF with your application! It can be a small passport size or any photo. It will help us remember your face!
10. When was the last time you attended the Retreat?
Never
2015
2016
Other ______
3 DB Camper Application 2017
11. How long do you want to stay at the Retreat?
Please check 1st, 2nd, or 3rd choice below.
Full Week: 4pm Sun Aug 27 – 9am Sat Sept 2
1st choice
2nd choice
3rd choice
Do Not Want
First Half Week: 4pm Sun Aug 27 – 2pm Wed Aug 30
1st choice
2nd choice
3rd choice
Do Not Want
Second Half Week: 11am Wed Aug 30 – 9am Sat Sept 2
1st choice
2nd choice
3rd choice
Do Not Want
12. Check box if you need more information on Personal Care Attendant services at the Retreat.
Yes.
This Retreat is for DeafBlind people 18 years and older. We are not able to offer PCA services: bathing, toileting, eating, dressing or medication. If you need this assistance, you must bring a staff or volunteer with you who can support you in these areas. We have more forms
for people who use such services.
13. My Blind status is:
Blind
Close Vision
Tunnel Vision
Ushers Syndrome
14. Please tell us a little more about yourself: How did you find out about the DB Retreat? Through friends, internet, or DB/Deaf service?
15. Have you joined other DB Retreats or camps before? If yes, where?
16. Do you have an active DB community in your area?
17. Do you have DB friends who want to join the Retreat
together?
18. What are your interests?
19. Comments:
3 DB Camper Application 2017
, ______
First name, Last Name
COMMUNICATION FORM
20. My Deaf status is:
Deaf
Hard-of-Hearing and can understand speech
Hard-of-Hearing but cannot understand speech
21. What is your preference for communication?
PTASL (Protactile ASL)
ASL (American Sign Language)
Signed language of another country
Signed language in English order
International sign
Finger spelling only
Speak and Listen to Speech
Speak and use Sign Language
Other
22. What format do you prefer for forms and information?
Large Print
Braille G1 (Uncontracted)
Braille G2 (Contracted)
23. While at camp, what format do you prefer for forms and information?
Large Print
Braille G1 (Uncontracted)
Braille G2 (Contracted)
24. Which do you prefer using?
Tactile (touch) Volunteer-Interpreter
Platform Volunteer-Interpreter
Close Vision Volunteer-Interpreter
Tactile or close vision depends on lights
FM System/Voice Interpreter
Read/Type on Computer or LVD
Other
25. If tactile, do you receive with
Left Hand
Right Hand
Both
26. Check all kinds of Volunteer-Interpreter you would like.
1a.
New People
Old Friends
No Matter
1b.
Women
Men
No Matter
1c.
Deaf
Hearing
No Matter
27. How tall are you?
5’ 4” or less
5’ 5” – 5’ 9”
5’ 10” or more
28. Check all kinds of activities you would like.
Physical activities (biking, jet ski, or swimming, etc.)
Calm activities (crafts, workshops, board games, etc.)
Tours out of camp (Town, mall, state park or casino) All
29. Names of your preferred Volunteer-Interpreters, if any. We
will try to match you with your preferred VolTerps, but
we cannot promise you will have those people.
30. Names of VolTerps you prefer NOT to be matched with, if
any.
31. Will you travel with a VolTerp?
Yes No
a. If yes, do you want that person for your VolTerp at camp?
Yes No
b. Name of VolTerp:
3 DB Camper Application 2017
, _____
First name, Last Name
HOUSING INFORMATION FORM
1. Do you smoke?
Yes No
2. Will you share a room with a smoker?
Yes No
3. Who are your preferred roommate/s?
,
(Name of person #1), (Name of person #2)
4. Do you have difficulty with stairs?
Yes No
5. Do you have difficulty with walking?
Yes No
6. Will you bring your dog guide?
Yes No
7. Will you share a room with a dog guide?
Yes No
8. Do you use wheelchair?
Yes No
9. If yes, will you be bringing your own?
Yes No
10. Do you use walker?
Yes No
11. If yes, will you be bringing your own?
Yes No
3 DB Camper Application 2017
, ______
First name, Last Name
ADDITIONAL INFORMATION REQUEST FORM
If you would like any information listed below, call or send this page to the Seattle Lighthouse for the Blind.
Scholarship Application Form (Due March 25th, 2017
postmarked)
Visitor Registration Form
Retreat Staff Application Form
Volunteer-Interpreter Qualifications
Information for Developmentally Disabled DeafBlind participants
Other, please specify:
*Application must be postmarked by March 14th
Email application to:
OR mail application to:
Lighthouse for the Blind, Inc.
Attn: DB Retreat
2501 S. Plum Street
Seattle, WA 98144
3 DB Camper Application 2017