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

Brief Overview of Position Descriptions:

1.  College Coordinator is responsible for mentors within their track, class observations, class lesson planning, and student 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, and student 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.  Registration, Recreation and Transportation Coordinator is responsible for arranging transportation to and from sites, arranging transportation for recreational activities, collecting and reviewing registration documents, completing check in and check out with students, and arranging and supervising recreation activities.  This person is on duty during all registration times, during all check outs, and each evening during the week.  This person is subject to the dorm curfew.  
4.  Dorm Coordinator is responsible for evening and/or overnight supervision of students, ensuring cleanness of dorms, assisting with serving of breakfast, serving as point of contact during evening and/or overnight hours, and ensuring students adhere to the schedule.   Dorm coordinators are not subject to dorm curfews.
5.  Mentors are responsible for teaching of assigned classes, supervising students, serving as a mentor, and assisting with meal duties.  These individuals are on duty from 7am to 6pm.  Each group would have about 4 students.  These persons are subject to the dorm curfew.  
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Name (first and last) *
Full Mailing Address (street, city, state, and zip code) *
I am applying to be a: *
All positions require interviews, unless you previously served our organization and the Director determine an interview is not necessary.  We reserve the right to conduct criminal background checks and contact references.
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How old are you? *
What is your home phone number? *
What is your cell phone number? *
What is your email address? *
I am currently: *
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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)?  Failure to request specific reasonable accommodations may result in denial of those accommodations. *
How do you access printed material? *
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In a short paragraph, please tell us why you wish to serve the EYE Retreat. *
In a short paragraph, please tell us what skills you can bring to the EYE Retreat. *
In a short paragraph, please tell us about your leadership experience. *
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? *
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.
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.
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.   Some students may not have the cognitive ability to make decisions on their own without your support and assistance.   *
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.  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 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 found at www.eyeretreat.org.   *
Is all the information you have provided on this form true and accurate? *
Print YOUR name here indicating you are submitting this form with true and accurate information. *
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.
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