13th annual Envisioning Youth Empowerment (EYE) Retreat Parent and Participant Application
Who: Youth with visual impairments who want to learn about college and careers.
What: A day seminar that provides an opportunity for mentoring and resource sharing by current college students and workers with visual impairments.
When: Saturday, November 13, 2021
Where: Columbus Metropolitan Library Southeast Branch 3980 S Hamilton Rd, Groveport, OH 43125

1. Self-Advocacy
2. College
3. Employment
4. Sports and Recreation
5. IEPs
6. Transition
7. Mentoring
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Name of Student (first and last) *
Address (street, city, state, and zip code) *
Who is attending? *
Our college track includes a mock college course. Our careers track include job shadowing opportunities.
Name of Parent (if attending):
What is your home phone number? *
What is your cell phone number? *
What is your email address? *
Currently, I am: *
I consider myself to be: *
Do you have any medical conditions besides blindness (be specific)? *
Do you have any food allergies or restrictions (be specific)? *
Do you require any other accommodations in order to participate (be specific)? *
How do you access printed materials? *
In one sentence, tell us why you wish to attend the EYE Retreat? *
Besides one day mini EYE Retreats, we host an annual week long summer camp each July in North Carolina. Are you interested in learning more? *
Please provide contact information for a family member or friend in the event of an emergency. *
Name, phone number(s), and relationship to you.
Is all the information you have provided on this form true and accurate? *
Print YOUR name here indicating you are submitting this application with true and accurate information. *
PARENTS/GUARDIANS: If the participant is under the age of 18, Print YOUR name here indicating you give permission for your son/daughter to participate and that you are submitting this application with true and accurate information.
The EYE Retreat is a 501c3 nonprofit organization. Its Board of Directors has developed a policy manual and other forms. They are available at www.eyeretreat.org. *
By submitting this application, you agree to adhere to the EYE Retreat policy manual. Further, you agree to a waiver of liability against the EYE Retreat and its volunteers and officers in connection with participating in the EYE Retreat.
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