15th annual Envisioning Youth Empowerment Retreat Student Application
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:  Saturday, July 29th to Saturday, August 5th.
Where:  The Governor Morehead School in Raleigh, NC and surrounding communities 

A Note to Parents/Guardians and Participants:

The EYE Retreat strives to provide an environment in which a simulated college experience is most realistic.  We ask for your support, flexibility, and communication.  If you have concerns, please let us know.  If you have ideas, send them our way.  If you'd like to volunteer your expertise, please sign-up!  In summary, some aspects of our program simply can't be changed because of legal concerns or facility use requirements.  However, other aspects of our programming can be adjusted and we have a strong track record of taking parent/guardian, staff, and participant feedback into consideration.  Please remember that the EYE Retreat has no paid staff.  Everyone, including myself, are volunteers.  The EYE Retreat's leadership is 100% led by adults with visual impairments who want to share their knowledge, passion, and experiences to make the future of our participants successful.  

Thank you,

Dr. Alan Chase
President and Director

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Name (first and last) *
Full Mailing Address (street, city, state, and zip code) *
I am applying for the: *
How old are you? *
What is your cell phone number? *
What is your email address? *
I am currently: *
I consider myself to be: *
Gender: *
My t-shirt size is: *
Do you have any medical conditions besides blindness (be specific)? *
Do you have any food allergies or restrictions (be specific)? *
Do you take any medications (be specific)? *
Do you require any other accommodations to participate (be specific)? *
How do you access printed material? *
In a short paragraph, please tell us what skills you want to learn while attending the EYE Retreat.  In other words, what career or college goal(s) do you have for yourself? *
Students coming to the EYE Retreat have the opportunity to select some of their classes just as they would in a college or job setting.  However, some classes are mandatory.  Please list here any specific topics you would like to learn more about. *
Please provide contact information for a friend or family member in the event of an emergency. *
Name, phone number(s), and relationship to you.
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), and relationship to you.
Were you referred to the EYE Retreat by a particular person?  If so, please list their name here.
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.
The EYE Retreat is planning a reunion on Saturday, August 5 to celebrate its 15th year of service.  We anticipate hosting a dance, a beach trip, and other activities.  Do you plan to attend the reunion on August 5? *
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 failure to honor my commitment may result in hardship for the EYE Retreat as the result of my actions.  If you are unable to attend, you must notify Dr. Chase in writing at alan.chase@eyeretreat.org by June 15, 2023.  If I do not attend the EYE Retreat in its entirety or fail to notify Dr. Chase of changes in my plans by the deadline, I promise to reimburse the EYE Retreat the amount of $327.00.   *
I understand that the mock college course, job shadowing experience, and other designated activities are mandatory.  This means that I must be in attendance, participate to the best of my ability, and advocate for myself if I am unable or unwilling to participate.  The mock college course  uses Google Classroom and I will be responsible for accessing all materials online and submitting assignments via Google Classroom. *
I promise to honor my commitment, check and use  email for communication frequently, and fulfill my duties and responsibilities as outlined in all EYE Retreat policies, procedures, and practices found at www.eyeretreat.org.   *
Is all the information you have provided on this form true and accurate? *
Payment:  The cost to attend the EYE Retreat is $100.  This includes 7 nights of housing, 21 meals, and a t-shirt.  Financial aid is available upon request.  Parents/guardians or students are responsible for transportation to and from Raleigh, NC.   *
Print YOUR name here indicating you are submitting this form with true and accurate information. *
Parent/Guardian print YOUR name here if participant 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.
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