2019 DOVE Teen Leadership Retreat
For: Deaf teens and CODAs who are rising 8th graders thru Seniors in high school

Dates: September 27-29, 2019 (Fri. 6:00 pm thru Sun. 1:00 pm)

Location: Camp Mikell
237 Camp Mikell Court
Toccoa, Georgia 30577

Cost: $250.00

Application Deadline: August 15, 2019

Applicants will be notified Sept. 1 or sooner if their application has been accepted. At the time of acceptance, a $50 deposit must be made to hold your spot. Remaining balance of $200 will be due by Friday, Sept. 20 unless other arrangements are made with Tammy Bowman, 706-296-8876 (voice/text), veathens@gmail.com.
Payments can be made on the website with a credit card or Paypal by clicking on the "Make a Payment" link, by using the Cash App to $DOVE1998, or by mailing a check or money order to:
DOVE
P.O. Box 80491
Athens, GA 30608
Make check or money order payable to DOVE.

ENROLLMENT IS LIMITED - FINAL SELECTION OF PARTICIPANTS WILL BE BASED UPON APPLICANT'S REQUIRED SHORT ESSAY (100 words or less) OR VIDEO PRESENTATION STATING WHY HE/SHE WANTS TO ATTEND THIS LEADERSHIP RETREAT. WRITTEN AND VIDEO SUBMISSIONS SHOULD BE SENT TO VEATHENS@GMAIL.COM. A PHONE OR DIRECT INTERVIEW CAN BE HELD IN LIEU OF A WRITTEN ESSAY OR VIDEO.


Participant's first name *
Your answer
Participant's last name *
Your answer
Preferred name for name tag
Your answer
Participant's text number if have phone
Your answer
Participant's email if have one
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Age at retreat *
Your answer
Grade (2019-20 school year) *
Your answer
Gender *
Required
Hearing Status *
Required
Communication Mode(s) *
Required
Child of Deaf Adult (CODA)? *
Required
Assisted Listening Device used, if any *
Required
Race/Ethnicity *
Required
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
County (NOT country) *
Your answer
T-shirt Size *
Parent/Guardian #1 - First and Last Name *
Your answer
Parent/Guardian #1 - relationship to camper *
Your answer
Parent/Guardian #1 - Email *
Your answer
Parent/Guardian #1 - Best phone number to be reached *
Your answer
At this phone number #1, can someone be reached by voice only, text only, or both? *
Required
Parent/Guardian #2 - First and Last Name
Your answer
Parent/Guardian #2 - relationship to you
Your answer
Parent/Guardian #2 - Email
Your answer
Parent/Guardian #2 - Best phone number to be reached
Your answer
At this phone number #2, can someone be reached by voice only, text only, or both?
Emergency Contact #1 - Full Name *
Your answer
Emergency Contact #1 - Relationship to you *
Your answer
Emergency Contact #1 - Best number to reach them *
Your answer
Emergency Contact #2 - Full Name
Your answer
Emergency Contact #2 - Relationship to you
Your answer
Emergency Contact #2 - Best number to reach them
Your answer
How did you hear about DOVE Teen Leadership Retreat? *
Your answer
List any camp activities in which, medically, you SHOULD NOT participate. *
Your answer
Do you have any food or drug allergies? If so, list them. *
Your answer
Medical Problems *
(check all that apply that have been diagnosed by a physician)
Required
Immunization Record *
Explain why you are not current with all immunizations:
Your answer
Other information you would like us to know about you:
Your answer
I understand that my application is not complete until I have submitted my essay, video, or had an interview. *
What format will you use to share with us why you would like to be selected to attend the Teen Leadership Retreat? *
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