Camp Abilities Camper

Camper’s First Name (required)

Camper’s Last Name (required)

Camper’s date of birth – please use the format (dd/mm/yyyy) (required)

Camper’s Gender (required)

Parent/Guardian Name (required)

Address Line 1 (required)

Area/Town (required)

City (required)

Eircode

Mobile (required)

Alternative Contact Phone:

Email (required)

Have you ever been to an overnight camp before? (required)

If Yes Name of Camp/s Attended (required)

What class are you in? (required)

What are your favourite subjects? (required)

What sports are you involved in, if any? (required)

Do you have a friend hoping to go to Camp Abilities?(required)

Name of friend hoping to attend (required)

Can you swim? (required)

Can you cycle? (required)

What are your favourite foods? (required)

What food do you not like? (required)

If you play an instrument, tell us what you play!

Do you have any pets? What are they and their names?

What would you hope to gain from attending Camp Abilities?

Is there anything else you would like to tell us aboout YOU? (required)

Vision Profile:

Is your child known to Vision Ireland (NCBI)? (required)

Please let us know who at Vision Ireland (NCBI) works with your child (required):

Please write the name of your child’s Eye Condition here (required):

Date of the most recent ophthalmology assessment – please use the format (dd/mm/yyyy) (required)

Level of Vision (required)

Level of acuity (Logmar Score) (required):

Is your child sensitive to light/sunlight? (required)

Information re light sensitivity (required):

Does your child need time to adjust to a change in lighting conditions? (required)

Information re adjusting to change of lighting conditions:

Does your child have difficulty seeing in low light levels/the dark (required):

Information re difficulty seeing in low light levels/the dark (required):

Does your child have difficulty with central vision? (required)

Information re difficulty central vision (required):

Does your child Read? (required)

Does your child use Glasses? (required)

(to select multiple options hold Ctrl for PC or cmd for Mac)

Does your child use Low Vision Aids? (required)

(to select multiple options hold Ctrl for PC or cmd for Mac)

Does child need additional lighting? (required)

Does your child use any Technological Devices as support? (required)

(to select multiple options hold Ctrl for PC or cmd for Mac)

Other Technological devices used:

Will your child be bringing devices with them? (required)

If someone is assisting your child for the first time, what do you feel is the most important and relevant piece of information they need to know to help support your child best? (required)

Mobility Section:

Walks with Long Cane? (required)

Walks with Sighted Guide? (required)

Uses a wheelchair? (required)

Walks with Other Device (required):

If you have chosen sometimes for any of the above questions, please specify when:

Does your child have difficulty detecting level changes (stairs, steps, slopes etc.? (required)):

Information re difficulty detecting level changes:

Has your child been given any other diagnosis? (required):

Details of other diagnosis:

Please specify specific type and degree of assistance required in each of the following areas (if any):

Eating:

Dressing:

Bathing:

Toileting:

Bedtime routine (i.e. light on/off):

Does your child have any medical, nutritional, allergy or other needs? Please be very specific with your details (required):

Additional Information:

We would like to have as much information about your child as possible. Please fill in below if there is anything else that would be useful for us to know about your child:

If your child is offered a place at Campabilities, they will receive a Camp T-shirt. Please let us know the size that would be required (required):

Please note, Camp Abilities is a residential camp, if your child is unable to stay over we may be able to offer a place as a day camper. Please mention here if your child is unable to stay at camp:

I acknowledge that the information I have given is accurate and up to date. I understand this information will be used by Vision Ireland (NCBI) for their Camp Abilities database and I select this check box in lieu of signature. (required)

Vision Profile:

Mobility Section:

Additional Information:

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