Summer Day Camp Form

Camper Name

First

Last

Guardian Name

First

Last

Relationship to Camper

Guardian Email Address

Guardian Phone

Address

Apartment/Unit

City

State

Emergency Contact Name

First

Last

Relationship to Camper

Emergency Contact Phone

How did you hear about Grandma Martyl Summer Day Camp?

This camp is for rising 6th to 12th grade students with low vision. What grade will your camper be entering in the fall?

What is your camper's current level of vision?

Fully blind (no usable vision)*

Low vision (some usable vision)

I use assistive devices (e.g., glasses, magnifiers) to support my vision

I have other vision challenges (please specify)

*If you selected fully blind, please note: This camp is specifically designed for individuals with low vision. While we are committed to supporting all participants, those who are fully blind will be considered on a case-by-case basis, and appropriate accommodations will be discussed. *Please be aware that we may not have specific resources such as braille materials or a one-on-one staff ratio to assist campers with no usable vision. Our goal is to create an environment that best supports those with low vision. If you are fully blind, please reach out to discuss how we can best meet your needs.

Please specify other vision challenges

Does your camper require any specific support or accommodations to ensure a positive camp experience? (If none, please indicate "none.")

Are there any medical or additional needs we should be aware of to provide the best care for your camper during camp? (If none, please indicate "none.")

Lunch and snacks will be provided every day. Does your camper have any dietary restrictions including food allergies or sensitivities?

PICK UP PERMISSIONS: Only the person(s) listed below will be allowed to pick up my camper from Spectrios. A valid driver's license may be asked for identification.

What is your camper's t-shirt size? Please indicate Youth or Adult S/M/L/XL

Camp Fees

I acknowledge that a $50 registration fee will be due on or before the first day of camp.

I give permission for my camper to be photographed by Spectrios Institute and grant the right to use photographs for marketing efforts associated with the Camp.

Yes

Would you like to sign up for our newsletter and keep up with all the happenings at Spectrios Institute for Low Vision?

Yes, I would like to sign up for the newsletter.

No, thank you!

If you are human, leave this field blank.