10th annual Envisioning Youth Empowerment Retreat Staff Application
"I Retreat from Challenge!"

BASIC INFORMATION ABOUT THE EYE RETREAT:
Who: Youth with visual impairments who want to learn about college and careers.
What: A week long camp that provides an opportunity for mentoring and resource sharing by current college students and workers with visual impairments.
When: July 14 to July 21, 2018
Where: The Governor Morehead School, NC State University & area businesses.

Brief Overview of Position Descriptions:

1. College Coordinator is responsible for mentors within their track, class observations, class lesson planning, and participant supervision. This person is on duty from 7am to 6pm and shares in an evening rotation for supervision. This person is subject to the dorm curfew.
2. Career Coordinator is responsible for mentors within their track, securing work site job experiences, class lesson planning, creating professional development for staff, and participant supervision. This person is on duty from 7am to 6pm and shares in an evening rotation for supervision. This person is subject to the dorm curfew.
3. Recreation Coordinator is responsible for arranging transportation to and from recreation sites and arranging and supervising recreation activities. This person is on duty each evening during the week. This person is subject to the dorm curfew.
4. Registration and Transportation Coordinator is responsible for arranging transportation at the start and end of the week, collecting and reviewing registration documents, completing check in and check out with participants, and arranging and supervising recreation activities. This person is on duty during all registration times and during all check outs. This person is subject to the dorm curfew.
5. Volunteer and Operations Coordinator is responsible for the supervision of all volunteers and coordinating the auxiliary components of the program (food services, cleaning, facility management, etc).
6. Dorm Coordinators are responsible for evening and/or overnight supervision of participants, ensuring cleanness of dorms, assisting with serving of breakfast, serving as point of contact during evening and/or overnight hours, and ensuring participants adhere to the schedule. Dorm coordinators are not subject to dorm curfews.
7. Mentors are responsible for teaching of assigned classes, supervising participants, serving as a mentor, attending professional development sessions and assisting with meal duties. These individuals are on duty from 7am to 6pm. These persons are subject to the dorm curfew.

Name (first and last) *
Your answer
Address (street, city, state, and zip code) *
Your answer
I am applying to be a: *
The College Coordinator and Career Coordinator must have a visual impairment. Dorm Coordinators, Mentors, and Volunteers may be either sighted or visually impaired. All positions require interviews, unless you previously served as a member of our staff and the Director determines an interview is not necessary. We reserve the right to conduct criminal background checks and contact references.
Required
What is your date of birth? *
MM
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DD
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YYYY
What is your cell phone number? *
Your answer
What is your email address? *
Your answer
I am currently: *
Required
I consider myself to be: *
Gender: *
My t-shirt size is: *
Do you have any medical conditions besides blindness (be specific)? *
Your answer
Do you have any food allergies or restrictions (be specific)? *
Your answer
Do you take any medications (be specific)? *
Please indicate here if you need assistance taking any medication.
Your answer
Do you require any other accommodations to participate (be specific)? Failure to request specific reasonable accommodations may result in denial of those accommodations. *
Your answer
How do you access printed material? *
Required
In a short paragraph, please tell us why you wish to be part of the EYE Retreat staff. *
Your answer
In a short paragraph, please tell us what skills you can bring to the EYE Retreat staff. *
Your answer
At the EYE Retreat we encourage our staff to lead classes on topics of interest to them. Please choose your top three choices from the list below or use “other” to suggest a new class. *
Required
Please provide contact information for a friend or family member in the event of an emergency. *
Name, phone number(s), and relationship to you.
Your answer
Please provide contact information for two references. These individuals should not be friends or family members. They could be teachers, professors, supervisors, mentors, or other professionals. *
Name, phone number(s), title, company, and relationship to you.
Your answer
Please describe here if you have ever been charged with a crime, convicted of a crime, suspended or expelled from work or school, asked to resign from a position, or been disciplined for violating established policies. *
If none of the above apply to you write "not applicable" below. If any of the above applies to you, please describe the circumstances surrounding the incident. Please note that disclosure of any of the above items does not automatically exclude you from being part of the EYE Retreat.
Your answer
Is all the information you have provided on this form true and accurate? *
I have requested all reasonable accommodations on this form and have disclosed any and all medical conditions. I understand that by not disclosing medical conditions or requesting accommodations in a timely manner, the EYE Retreat may not be able to accommodate my specific needs. *
I understand that my position may have supervision responsibilities and direct contact with minors and adults with disabilities. I understand that failure to honor my commitment or fulfill my duties may result in hardship for the EYE Retreat as the result of my actions. I promise to honor my commitment, check and use official EYE Retreat email for communication frequently, and fulfill my duties and responsibilities as outlined in all EYE Retreat policies, procedures, and practices. *
Print YOUR name here indicating you are submitting this form with true and accurate information. *
Your answer
Parent/Guardian print YOUR name here if staff applicant is under the age of 18 indicating your are submitting this form with true and accurate information and that you give permission for your son/daughter to submit this application.
Your answer
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