Camp Eye to Eye Registration

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Eye to Eye
Camp Eye to Eye 2017 Registration
Dear Parents and Guardians:

Camp Eye to Eye is the only summer program that pairs kids with learning disabilities (LD) and ADHD with similarly-labeled counselors. Campers and counselors use Eye to Eye's art-based curriculum to create projects that help campers to understand their unique ways of learning and thinking, build self-esteem, and develop self-advocacy. 

Camp Eye to Eye runs for one one week, July 10-14, in partnership with the 92nd Street Y, in New York City.

To register your student for Camp Eye to Eye, please complete the following Camper Registration Form.

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Eye to Eye
To be Completed by Camper's Parent/Guardian
Camper Information
Thank you for your interest in Camp Eye to Eye 2017. If you have any questions about camp or registration, please contact Michaela Regehr at mregehr@eyetoeyenational.org.










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Eye to Eye
To be Completed by Parent/Guardian
Parent/Guardian Contact Information
Parent/Guardian 1









Parent/Guardian 2





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Eye to Eye
To be Completed by Camper's Parent/Guardian
Health
Please note that the 92nd Street Y requires an up-to-date physical and other medical forms. The forms will be sent to camper families and must be completed by May 1, 2017.


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Eye to Eye
To be Completed by Camper's Parent/Guardian
Learning Disability/ADHD Information
Camp Eye to Eye is for students with language and/or math-based learning disabilities and/or ADHD as a primary diagnosis. Campers with other special needs should consider the 92nd Street Y's Camp Tova or Camp Bari Tov.

As is the practice of all 92nd Street Y Summer Camps for children with learning disabilities, ADHD, and other special needs, parents/guardians must send their camper's most recent diagnosis documentation, IEP, 504 Plan or relevant outside report. The documents must be mailed (1430 Broadway, Suite 602, New York, NY 10018) or emailed (mregehr@eyetoeyenational.org) upon registering for Camp Eye to Eye. A camper's registration is not complete until Eye to Eye has received this documentation.

Additionally, after filling out the registration form and sending the camper's diagnostic information to Eye to Eye, parents/guardians must schedule an introductory interview with a Camp Eye to Eye staff member. Eye to Eye staff will contact parents/guardians about the interview after receiving campers' registration materials. 

The registration process is designed to ensure that the Camp Eye to Eye program is suitable for every camper. Eye to Eye reserves the right and has sole discretion to reject the participation of a child if a child does not have a language or math-based learning disability and/or ADHD as a primary diagnosis.









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Eye to Eye
To be Completed by Camper's Parent/Guardian
Optional Questions
The following questions are optional. Your answers allow Eye to Eye to better understand and serve our students.





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Eye to Eye
To be Completed by Parent/Guardian
Payment

Camp Eye to Eye costs $900, and a $450 deposit is required to reserve a spot. You have the option of paying the full tuition with your registration. Camp Eye to Eye cancellation date is April 1, 2017, after which deposits will not be refunded. 

The second payment of  $450 is due to Eye to Eye by April 1, 2017.   


Upon submission of this form, you will be re-directed to Eye to Eye's payment processing website. A payment link will also be emailed to you.


More information on how to make the second camp tuition payment will be sent to you with additional paperwork.

A limited number of scholarships are available on a first come, first served basis to families with demonstrated need. Please email Michaela Regehr at mregehr@eyetoeyenational.org to inquire.

Waiver
In consideration of my child being permitted to participate in the Camp Eye to Eye, I do hereby agree to release, indemnify, and forever discharge Eye to Eye against any and all liability and responsibility for any claim or cause of action on account of any personal injury, accident, damage, expenses, or other loss caused, suffered, or incurred by my child or any other person(s) or entity during, arising out of, or in any way associated, directly or indirectly, with my child’s participation in the activities associated with Eye to Eye (including but not limited to travel incident to my participation), or for contribution or indemnification in respect to any claim made against me by any participant in Eye to Eye or any other person or entity in connection therewith.


I have been advised of the nature of the Eye to Eye program and the activities associated with it. I understand that my child’s participation in Eye to Eye is subject to any rules, procedures, and regulations outlined for me by the Eye to Eye staff, or any other person(s) conducting the activities associated with Eye to Eye. Additionally, I understand that although my child is expected to be involved in the program’s activities, my child is not required to participate in any activity with which he or she is uncomfortable and I acknowledge that his or her participation in Eye to Eye is entirely voluntary. I recognize that there are hazards and risks which may result in physical injuries or death and understand that Eye to Eye neither assumes any responsibility for actions of any persons whether or not a participant in the program, nor provides any insurance for participants in the Program. Additionally, I voluntarily agree to assume all risks and hazards to my child inherent in participation in Eye to Eye.

I acknowledge that I have an obligation to disclose pertinent medical information to Eye to Eye staff before the program and to disclose any injuries, illnesses, etc. my child may suffer or may have suffered during the program. Eye to Eye staff will not be responsible for distributing medication. I agree to assume all risks and hazards to my child resulting from any undisclosed injuries, illnesses, etc. Further, I authorize and empower Eye to Eye leaders and/or any other person acting in a supervisory capacity with respect to Eye to Eye, at any time and from time to time during the Eye to Eye program, to take such action as is deemed by Eye to Eye leaders or such other person(s) as necessary or desirable for my welfare when my child is sick or disabled, including without limitation, medical treatment and/or surgery, and that I will pay for any and all cost and expenses so incurred in the exercise of such discretion.

Eye To Eye periodically uses electronic and traditional media for publicity and educational purposes. I give permission to Eye To Eye, Inc., their assigns, licensees, and legal representatives the irrevocable right to use my child’s name, picture, photograph, portrait, visual likeness, or voice in all forms and media in all manners, including photo, film, audio and video representations, for nonprofit, public purposes, and I hereby waive any right to inspect or approve the finished product that may be created in connection therewith. I understand that I will not receive any monetary compensation for the contribution and/or use of the contribution. I also hereby release Eye to Eye and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above. All copyright and any other rights from my contribution are assigned to and shall be the property of the Eye to Eye in perpetuity.

I acknowledge that I have read and understand the above statements. This release and waiver has been executed on behalf of myself, my heirs, and assigns, and has been made with full knowledge of possible risks involved. This instrument has been executed in and shall be interpreted according to the laws of New York.


Thank You!

Thank you for registering for Camp Eye to Eye! We look forward to seeing you this summer!


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