Weekend at the Wood

Annual Southeast Regional Teen/Young Adult Deaf-Blind Retreat & Parent Event Sponsored by: Deaf-Blind Projects from: GA, FL, SC, MS, TX, TN and NCDB and HKNC Southeast Region January 15-18, 2010

Where: Rotary’s Camp Florida 1915 Camp Florida Road Brandon, FL, 33510

When: Friday, January 15, 2010 --Monday, January 18, 2010 TRIP TO BUSCH GARDENS on Sunday is at participant’s expense Location: Rotary’s Camp Florida was founded in 1991 as a year-round facility on 18 acres DEADLINE for Registration: of woodland December near Tampa,18, 2009 Florida. GA Contact: The Martha camp Veto, has 478-550-2367, residential [email protected] cabins, a dining hall, 2 an assembly hall with a stage and Karaoke, an archery range, paddle boats and canoes on its 2 lakes.

Cost: Travel and Registration fees for participants are covered by the state deafblind projects. Reservations required by the stated deadline. The cost of attending Busch Gardens is at the participant’s personal expense. Participants must bring their own spending money to cover outside activities and food off site.

Meals: Meals will be provided for Friday dinner, Saturday: Breakfast, Lunch, Dinner Sunday: Breakfast

For Information or to Register Contact your state deafblind project

FL: Emily Taylor-Snell or Michelle Wahlmeier Florida Outreach Project Serving Chldren and Adults who are Deaf-Blind University of Florida 1600 SW Archer Rd, P.O. Box 100234 Gainesville, FL 32610 Phone: 352-273-7530 800-667-4052 813-817-1873 ETS Cell Fax: 352-273-8539 Email: etsnell.ufl.edu [email protected] GA: Martha Veto TN: Donna Consacro SC: Tracy Makison TX: Jenny Lace MS: Toni Hollingsworth DEADLINE for Registration: December 18, 2009 GA Contact: Martha Veto, 478-550-2367, [email protected] 3 DEADLINE for Registration: December 18, 2009 GA Contact: Martha Veto, 478-550-2367, [email protected] 4

Registration Form DEADLINE for Registration: December 18, 2009

Teens/Young Adult Information:

Participant Name: ______

Date of Birth: ______Age: ______

Social Security Number: ______--______--______(Required for projects to cover expenses)

Teen’s Phone: ______Teen’s Email: ______

Address:______

Address: ______Street Name Apartment # City: ______State______Zip Code______

Responsible Person Accompanying Participant Information:

Name ______

Social Security Number: ______--______--______(Required for projects to cover expenses)

Email address of responsible person accompanying participant: ______

Day Phone Number (______) ______--______AREA CODE PHONE NUMBER Night Phone Number (______) ______--______AREA CODE PHONE NUMBER Cell Phone Number (______) ______--______AREA CODE PHONE NUMBER Address: ______Street Name Apartment # City: ______State______Zip Code______DEADLINE for Registration: December 18, 2009 GA Contact: Martha Veto, 478-550-2367, [email protected] 5

Participant’s Parent/Guardian Information if different than above:

Name ______

Parent E-mail:______

Day Phone Number (______) ______--______AREA CODE PHONE NUMBER Night Phone Number (______) ______--______AREA CODE PHONE NUMBER Cell Phone Number (______) ______--______AREA CODE PHONE NUMBER Address: ______Street Name Apartment # City: ______State______Zip Code______

When are you coming and how long are you staying? Please write the total number people who will need meals and/or accommodations for Friday, Saturday and Sunday. ______people arriving Friday ______people staying at camp Friday and Saturday nights ______people staying at camp Sunday night ______people attending Busch Gardens on Sunday, January 17th

How are you getting there?

___ I’m coming with a family member or other adult. ___We’re driving to camp. ___ We’re flying and need someone to pick us up at the Tampa airport. Please call and let’s set up who will pick me up

___ I’m coming with a group from my state – transportation arranged by my deaf blind project DEADLINE for Registration: December 18, 2009 GA Contact: Martha Veto, 478-550-2367, [email protected] 6 Teen Information: To help us provide the appropriate support so you can get the most out of the weekend please check the best choice for EACH!

Participant’s Name: ______

I need reading materials in: ____ regular print ___ large print ___ Braille

I need an assistive listening device: ___ yes ___no If yes: ___I’ll bring it __ I need you to bring a sound system

I use sign language and need an interpreter: ___yes ___ no If yes: ___Close Vision ___Platform ASL ___Tactile

SSP Needs: SSP stands for Support Service Provider. Most SSPs provide visual and auditory information about the environment, sighted guide, and interpret.

To help us get SSPs coordinated before you arrive, please give detailed information about the kinds of help you need – travel, interpreting, voicing, etc

I need an SSP: ____ pretty much all the time for: ______

___ at specific times, like:______

___ I need little or no help from an SSP, maybe only ______

___ I’m bringing an SSP with me ___ I need you to provide an SSP

Please indicate medical conditions, including allergies, other than vision and hearing loss that we should know about: ______DEADLINE for Registration: December 18, 2009 GA Contact: Martha Veto, 478-550-2367, [email protected] 7 Southeast Regional Teens/Young Adults with Deafblindness Group Code of Conduct Agreement:

Participant Name: ______DOB: ______

Event: Southeast Regional Teen/Young Adult Retreat:January 15-18, 2010

The Deaf-Blind projects from Georgia, Florida, South Carolina, Tennessee, Mississippi, and Texas are not responsible for the supervision of participants. Minor participants (under the age of 18) must be accompanied by a responsible adult. Participants, including those over the age of 18, must agree to and obey to the rules and regulations specified in the Code of Conduct.

All rules and regulations governing program activities and events will be discussed with leaders, advisors and participants.  Participants are expected to attend all event sessions as part of a planned program exhibiting positive character and behavior including (but not limited to) trustworthiness, responsibility, respectfulness, caring, citizenship and fairness.  Participants are expected to be responsive to the reasonable requests of the leaders and respectful of the needs for their personal safety and the safety of others.  Participants should dress appropriately, use appropriate language and respect the rights of others.  Participants may not use alcohol, drugs, or tobacco, nor be associated with or remain in the presence of others using the substances.  Participants may not behave recklessly, engage in sexual misconduct, assault, threaten or harm another person nor may they misuse or abuse public or private property.

 Participants may have access to computers and facilities. Computers use is for educational purposes. Participant may not access in appropriate websites. Realizing these guidelines are not “all inclusive” the Deaf-Blind Projects Staff reserve the right to make adjustments to these policies to ensure the safety of all participants. CONSEQUENCES OF MISBEHAVIOR DEADLINE for Registration: December 18, 2009 GA Contact: Martha Veto, 478-550-2367, [email protected] 8 Participants and adults who observe a breach in the Code of Conduct should report the misbehavior to the appropriate leader. Participants misbehaving will have the opportunity to explain their actions to leaders in charge of the activity. Personnel in charge the event will determine what disciplinary action should be taken.

Any participant found in violation of the actions listed below will have his/her parents/guardians notified, and the participant may be sent home at the parents’ or their own expense: 1. Breaking curfew or disturbing the peace 2. Unexcused absences from the activities of an event 3. Reckless behavior 4. Use of foul or offensive language 5. Possession or use of tobacco 6. Breach of the Code of Ethics 7. Remaining in the presence of those using alcohol, illegal drugs or tobacco 8. Possession or use of illegal drugs or alcoholic beverages 9. Theft, misuse or abuse of public or personal property 10. Sexual misconduct 11. Possession of weapons or fireworks 12. Unauthorized absence from the premise of the event 13. Assault or personal harm 14. Leaving premises without notifying the event Staff

PARENT/GUARDIAN & Participants AGREEMENTS I have reviewed the Code of Conduct and agree to all of its provisions.

Participant Signature ______Date______

I have reviewed the Code of Conduct and agree to all of its provisions. I certify that my child is participating in the Southeast Regional Teen/Young Adult Retreat with my knowledge and consent. I have read and understand all of the above policies..

______(______)______Parent/Guardian Signature Phone Date *Participants 18 and older do not require parent signature. DEADLINE for Registration: December 18, 2009 GA Contact: Martha Veto, 478-550-2367, [email protected] 9 Southeast Regional Teen Group Medical Information, Permission to Treat & Release of Liability Event: DB Winter Retreat , Brandon, Florida: January 15-18, 20 10

Name______Date of Birth______Gender______Address______Street Apt: ______City State Zip

Parent/Guardian Information

Name______Home Phone: (______) ______-______Work Phone: (______) ______-______Cell Phone: (______) ______-______Best Contact Number: (______) ______-______

Please list the names of two adults other than parent/guardian who may be contacted in case of emergency.

Name______Home Phone (______) ______-______Work Phone (______) ______-______Cell (______)______-______

Name______Home Phone (______)______Work Phone (______)______-______Cell (______)______-______

Medical Information

Name of Physician______Phone (______) ______-______

Date of Last Physical Examination ______Drug Allergies______Other Allergies______Describe any physical limitations______Describe any recent illness or injury______Is there a history of heart condition, high blood pressure diabetes asthma epilepsy rheumatic fever:______DEADLINE for Registration: December 18, 2009 GA Contact: Martha Veto, 478-550-2367, [email protected] 10 INSURANCE COVERAGE INFORMATION Photo copy of insurance card must be included (Please copy front and back of insurance card)

Insurance Holder (Employee) Name)______Name of Insurance Provider:______Group Name: ______Group Number:______

Over the Counter & Prescription Medication Summary

Participant’s Name ______

Does this participant need assistance in taking medications? ______

Please list all medication including over the counter medications. Additionally, participant of legal age, parent/guardian should list any over the counter medication that may be taken or given to the participant in case of illness. GSAP personnel may not administer over the counter or prescription medication without parental/guardian approval unless prescribed by medical personnel. Participants are expected to provide all medication(s) listed and administer the medication. Additional copies of this page may be made as necessary.

I am the parent/guardian of ______and give permission for the (Name of child/participant) medications listed to be administered to my child as directed.

______I am of legal age and responsible for taking medications myself. I do not need assistance.

______I am of legal age and am responsible for taking medications myself. I require assistance.

______Signature Parent/Guardian/Participant 18 years and older Date (Students over the age of 18 must provide a signature. Parents may sign below as a witness.) ______Witness Relationship to Participant Date DEADLINE for Registration: December 18, 2009 GA Contact: Martha Veto, 478-550-2367, [email protected] 11 Medication List: All medications must be listed including aspirin, Tylenol, cold medications etc., Prescription medications must have participants name written on prescription bottle or package.

Name of Medication:

What illness/condition is medication being taken for:

Describe dosage and special instructions:

Is medication self administered?

Dates for administration: ------Name of Medication:

Dates for administration ------Name of Medication:

Dates for administration: ------Name of Medication:

Dates for administration: DEADLINE for Registration: December 18, 2009 GA Contact: Martha Veto, 478-550-2367, [email protected] 12

Release and Hold Harmless Agreement/Permission to Provide Medical Treatment

PARENT/GUARDIAN/PARTICIPANT 18 YEARS OF AGE AND OLDER

Participant’s Name: ______

DOB: ______

In the event of an emergency, I authorize any Southeast Regional Teen Group Staff and/or Advisors to organize and administer any required medical treatment or first aid procedure, and/or take the above named child to a hospital emergency room for treatment. I realize and agree that it is the responsibility of each individual or family to provide his or her own medical insurance. The undersigned hereby forever releases, discharges, and covenants to indemnify and hold harmless the Southeast Regional Teen Group *, its members, volunteers, sponsors or any other supporting agencies, any other person, firm, corporation charged or chargeable with responsibility, liability, their heirs, administrators, executor, successors, and assignees from any and all claims, demands, cost, expenses, loss of services, actions and causes of action belonging to the undersigned or arising out of any act or occurrence in connection with and particularly on account of all personal injury, wrongful death, disability, property damage, loss or damages of any kind sustained or that may hereafter be sustained arising out of the matter described herein or in consequences of the full and complete release of any and all claims.

I have read and fully understand the above information and agree to these terms.

Signed______

Relationship to workshop participant: ______Date______

This document must be signed by a parent or legal guardian if participant is under the age of 18

* The Southeast Regional Teen Group includes: The Florida Outreach Project and Staff, University of Florida, the Board of Regents of the University System of Florida, The Georgia Sensory Assistance Project and Staff, Georgia State University, the Board of Regents of the University System of Georgia >>>>>>>>>>> DEADLINE for Registration: December 18, 2009 GA Contact: Martha Veto, 478-550-2367, [email protected] 13

AGREEMENT AND COVENT NOT TO SUE: Furthermore, I am aware that participation in this event includes risk including, but not limited to, transportation to/from event, theme park rides, sports and recreational games, ropes courses, water activities, hiking, as well as risks that are not foreseeable. For the sole consideration of the deaf-blind projects arranging for participation in the Southeast Regional Teens/Young Adults with Deafblindness Group (SE Regional Teen Group), I hereby release and forever discharge the Southeast Regional Teen Group* their members individually, and their officers, agents and employees from any and all claims, demands, rights and causes of action of whatever kind that I may have, either on my own behalf or in my capacity as a legal representative of my child or myself (individuals over the age of 18), arising from or in any way connected with my child’s participation in SE Regional Teen Group events. I further covenant and agree that for the consideration stated above I will not sue any or all of the entities of the Southeast Regional Teen Group*, it’s members individually, its officers, agents or employees for any claim for damages arising or growing out my child’s participating in the program. I understand that the acceptance of this Release, Waiver of Liability, and Convent not to Sue the Southeast Regional Teen Group* shall not constitute a waiver, in whole or part, of sovereign immunity by said Board, its members, officers, agents, and employees.

I certify that my child is participating in SE Regional Teen Group events specifically the Southeast Regional Teen/Young Adult Family Event, Brandon Florida, January 15-18, 2010 with my knowledge and consent. I have read and understand all of the above.

______Signature: Parent/Guardian/ Individuals 18 years and older Date (Students over the age of 18 must provide a signature. Parents may sign below as a witness.)

______Witness (Parent/Guardian/Other) Relationship to Participant Date

* The Southeast Regional Teen Group includes: The Florida Outreach Project and Staff, University of Florida, the Board of Regents of the University System of Florida, The Georgia Sensory Assistance Project and Staff, Georgia State University, the Board of Regents of the University System of Georgia >>>>>>>>>>> DEADLINE for Registration: December 18, 2009 GA Contact: Martha Veto, 478-550-2367, [email protected] 14 Permission to Use Photographs Spontaneous photographs may be taken during Southeast Regional Teen Group events. We would appreciate permission to use photographs of you/your child in project newsletters, websites, or presentations that promote awareness of the state deafblind projects, the National Consortium on Deaf-Blindness (NCDB), the American Association of the Deaf-Blind (AADB) and deafblindness. The Southeast Regional Teen Group is committed to protecting the privacy of individuals who participate in our events. Therefore, we will not release any personal information, specifically, names, addresses, and phone numbers, or photographs, without your written consent. In the future, should you decide to withdraw permission for Southeast Regional Teen Group use of your or your child’s photograph, you can opt out by faxing a written request to the Georgia Sensory Assistance Project 478-550-2367 or at emailing Martha Veto at [email protected].

I understand that my or my child’s photograph with his/her name may be used in the newsletters, websites or presentations by any of the cooperating groups that comprise the Southeast Regional Teen Group.

Please Check and Sign:

For participants under 18 years of age: ______Yes, I give permission to the Southeast Regional Teen Group to display photographs of my child, ______, individually or in a group.

______No, I do not give permission to the Southeast Regional Teen Group to display photographs of my child, ______, individually or in a group

Signature: ______Date: ______

Relationship to youth______

For participants 18 years and older: ______Yes, I give permission to the Southeast Regional Teen Group to display photographs of me individually or in a group.

______No, I do not give permission to the Southeast Regional Teen Group to display photographs of me individually or in a group

Signature: ______Date: ______