Has the camper attended Camp Bloomfield before? * Required Name * Required
First
Last
Date of Birth * Required How much can your camper see? * Required Additional disabilities/support needs (in addition to blindness/visual impairment) * Required What formats/supports does your camper use? (Check all that apply) * Required Does your camper need staff support navigating new environments? * Required
Primary Contact Name * Required
First
Last
Email * Required Please provide the best email address for event communication.
Address * Required
Secondary Contact (alternate adult contact) We strongly recommend adding a second parent/guardian or alternate adult contact in case we can’t reach you. Check here to fill out information for a secondary contact.
Secondary Contact Name * Required
First
Last
Email * Required Address * Required
Same as Primary Contact
Attending Family Roster Households with more than one B/VI camper one application per blind/visually impaired camper .Family Roster only once (on the first application you submit ).everyone attending , including all B/VI campers .additional B/VI camper from the same household , select “No” below so you won’t be asked to enter the roster again .primary contact email —please use the same email on all applications for your household.
Do you need to complete the Family Roster on this application (only select "no" if you’re submitting a second B/VI camper application from the same household)? * Required For additional B/VI campers in the same household: please do not re-enter your family roster. Complete this application for the camper only (including camper-specific health/support). We will link applications by primary contact email.
Immediate family only * Required Included B/VI camper in family roster * Required
PHYSICAL: Does your camper use any of the following? * Required What support does your camper need to participate safely? * Required
INDEPENDENCE: Does your camper need assistance with any of the following? * Required Please briefly describe what support is needed and what works best. * Required
Does your camper have any of the following? (Check all that apply) * Required Please Describe / provide further information: * Required
Does your camper use a rescue inhaler (e.g., albuterol)? * Required In the past 12 months, has your camper visited the ER or urgent care for asthma or breathing problems? * Required Are your camper’s asthma symptoms triggered by any activities or environments? * Required Are the camper's seizures controlled with medication? * Required Seizures: Typical length + What helps after / Precautions * Required
Diabetes type: * Required Does the camper use insulin? * Required How is blood sugar typically monitored? * Required Does the camper use a correction or sliding-scale insulin plan? * Required If requested, are you able to share the written plan through CampDoc in April? * Required In the past 12 months, has the camper had any of the following? (Check all that apply) * Required At camp, diabetes management will require: * Required Does the camper have glucagon available (for severe low blood sugar) * Required If yes, what type? * Required Does exercise typically cause low blood sugar for the camper? * Required Does your camper have a history of blood sugar highs or lows that you’re aware of, even if they don’t have diabetes? * Required What triggers can cause your camper’s blood sugar to go very high or very low? (Check all that apply) * Required
Does your camper take any medications during camp (including OTC/as-needed)? * Required Any meds need refrigeration? * Required Does your camper have emergency/rescue medication they may need to access quickly at camp? * Required Camp has a busy schedule and a different routine. What help will the camper need to administer medication? * Required
Recent Health Events Has your camper had any major health changes, surgeries, or hospitalizations in the past 12 months? * Required Please describe * Required
Physician guidance (if needed): If our team requests it, are you able to provide a brief physician note confirming the camp environment is appropriate for your camper? * Required Please share any concerns or context you’d like us to know * Required
Family members: Health, Safety & Support Snapshot Do any attending family members (other than the blind/visually impaired camper) have any health/safety needs we should be aware of for camp? * Required Briefly describe (who it is + what we should know for safety) * Required
More detailed information will be required once family is confirmed.
Does the camper have challenges with any of the following: * Required Triggers to avoid * Required
Strategies that work best * Required
Safety concerns we should know * Required
Camp Logistics How will the family be arriving at Camp Bloomfield? (Please select one option): * Required
Ethnicity * Required
Releases and Disclosures COVID Information * Required While participating in events held or sponsored by Wayfinder Family Services, consistent with CDC guidelines, participants are encouraged to practice hand hygiene, “social distancing” and wear face coverings to reduce the risks of exposure to COVID-19. Because COVID-19 is known to be contagious and is spread mainly from person-to-person contact, Wayfinder Family Services has put in place preventative measures to reduce the spread of COVID-19. However, Wayfinder Family Services cannot guarantee that its participants, volunteers, partners, or others in attendance will not encounter COVID-19.
I acknowledge that my participation (or my child’s) in Wayfinder Family Services program is at my own risk.
ACTIVITY PERMISSION AND RELEASE * Required I hereby grant participant named above permission to participate in all activities offered by or through Wayfinder Family Services, with the exception of those activities indicated above. The undersigned parent, guardian, or custodian of the above named participant hereby joins in the foregoing Activity Opt-Out Form and hereby stipulates and agrees to save and hold harmless, indemnify, and forever defend Wayfinder Family Services, their directors, officers, agents, employees, and volunteers from and against any claims, actions, demands, expenses, liabilities (including reasonable attorney fees) for negligence as a result of said participant’s participation in the activities of Wayfinder Family Services and his or her use of the property, animals, and facilities. I, on behalf of said participant, further agree not to sue Wayfinder Family Services, its directors, officers, agents, employees, and volunteers as a result of any injury that said minor suffers from negligence in connection with his/her participation in the activities of Wayfinder Family Services.
I have read and agree to the ACTIVITY PERMISSION AND RELEASE
AUTHORIZATION FOR TREATMENT / CONSENT, RELEASE, AND COVENANT * Required Medical Authorization:
I have read and agree to the AUTHORIZATION FOR TREATMENT OF ADULT CONSENT, RELEASE, AND COVENANT:
PARTICIPANT/PARENT/GUARDIAN MEDIATION AND ARBITRATION AGREEMENT: * Required This is an Agreement to mediate and arbitrate all unresolved disputes arising from the educational, recreational, special education school, and residential services between the undersigned camper and/or their legal guardian and the Wayfinder Family Services.
I, the undersigned participant, or, if applicable, the parent/guardian of the minor participant named below, wish for the participant to take part in the programs of Wayfinder Family Services and have read and agree to the PARTICIPANT/PARENT/GUARDIAN MEDIATION AND ARBITRATION AGREEMENT
Media Release * Required Permission is hereby given to WAYFINDER FAMILY SERVICES® to use audio, video recordings, photographic and electronically created images of the camper noted in this application for public view, including publications, websites or social media sites. Usage of any images or audio is without compensation to said person or to the undersigned on his/her behalf, or individuality.
I have read and agree to the MEDIA RELEASE
Special Event Waiver * Required In consideration of the acceptance of my family’s participation in the following activity listed on this form, I, the undersigned, intending to be legally bound, do hereby for myself and my family (including heirs, executors, administrators and assigns) forever waive, release and discharge any and all rights, claims and actions for damages that we may have, or that may hereafter accrue to us against WAYFINDER FAMILY SERVICES, including all of its officers, directors, members and volunteers.
I have read this waiver and am in agreement with its contents.
Hold Harmless * Required I agree to the privacy policy.I have read the Hold Harmless Release and am in agreement with its contents.
In consideration of the acceptance of my family’s participation in the activity listed on this form, I, on behalf of myself and my family, agree if any claim for personal injury or wrongful death is commenced against WAYFINDER FAMILY SERVICES (including its officers, directors, members and/or volunteers), we will defend indemnify and hold harmless WAYFINDER FAMILY SERVICES, from any and all claims or causes of action for personal injuries, property damage or wrongful death that hereafter accrue, arise out of, result from, or are caused directly or indirectly by my family’s participation in this activity.
Signature Confirmation * Required By entering my full name below, I confirm that I have read, understood, and agree to the terms outlined in the Waiver & Release of Liability above. I understand that typing my name serves as my digital signature and legally binds me to the terms of this agreement.
