EnVision Clinic
Is the camp attendee Under 18?
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Yes
No
Camp Attendee Information
Participant's Name
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First Name
Last Name
Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you live within Chattanooga city limits?
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Yes
No
Ethnicity
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Please Select
Asian
Black
Hispanic
White
Other
Sex
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Male
Female
Prefer not to say
Other
Date of Birth
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-
Month
-
Day
Year
Date
Age
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Grade
*
Does the participant currently use any of the following devices:
Glasses or contact lenses
Hearing aid
Wheelchair
Walker or Rollator
Crutches or support cane
Mobility or "white" cane
Communication system or device
Smartphone or tablet
Laptop or desktop computer
Does the participant currently use any of the following applications:
Voiceover
Talkback
JAWS
NVDA
ChromeVox
Seeing AI
Be My AI
Does the participant require any accommodations we need to be made aware of to ensure they have a great camp experience?
Lunch will be provided at camp. The participant will also be out in public spaces as a part of camp activities. Does the participant have any food or environmental allergies we need to be made aware of?
T-shirt Size
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Small
Medium
Large
XL
2XL
3XL
How did you hear about EnVision Camp?
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Please Select
Social Media
Mailing
Word of Mouth
Email
Assistive Technology Client
Other
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Medications
Please list ALL oral medications the participant takes, including OTC medicines. Bring all oral medications to camp in original containers with the participant’s name, dosage, and administration times. Medications must be given to the Camp Nurse or Staff by a parent or guardian. DO NOT ALLOW MINORS TO BRING MEDICATIONS. Attach additional paper, if necessary. Please make every effort to administer medications to your child prior to daily arrival at camp.
Medications
Please make every effort to administer your medications prior to daily arrival at camp. EnVision camp staff cannot administer medication. If you need to bring medication with you please make sure it is properly labeled and stored.
Medication List
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Parent/Guardian Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you live within Chattanooga city limits?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Emergency Contact Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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