14th annual Envisioning Youth Empowerment Retreat Participant Application
BASIC INFORMATION ABOUT THE EYE RETREAT:
Who:  Youth with visual impairments and their families 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 23th to Saturday, July 30th.
Where:  The Governor Morehead School, NC State University & area businesses.

NEW:  We are excited to host the 2nd annual Family Retreat in 2022.  We invite family members to join us on Saturday, July 23 and Sunset, July 24.  You can sign-up below.

A Note to Parents/Guardians and Participants:

The EYE Retreat strives to provide an environment in which a simulated college experience is most realistic.  However, our participants range in age from minors to adults.  Also, our participants oftentimes have additional disabilities, besides blindness.  Finally, facility and resource limitations impact our programming too.  As a result, we walk a fine line in supervising all participants, providing a quality experience, and balancing the many partnerships we have to make our program a success.  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.  Be sure to show your appreciation to our staff for their dedication.

Thank you,

Dr. Alan Chase
President and Director


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Name (first and last) *
Address (street, city, state, and zip code) *
I am applying to be a: *
Required
Will a parent or family member be attending our Family Retreat on July 23 and July 24? *
Required
If a parent or family member is attending the Family Retreat, please provide their name and phone number.
If a parent or family member is attending the Family Retreat, please describe their goal(s) for attending. In other words, what do they want to learn?
How old are you? *
What is your cell phone number? *
What is your email address? *
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)? *
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? *
Required
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? *
Participants 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.
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.
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 failure to honor my commitment as a participant of the EYE Retreat may result in hardship for the EYE Retreat or other potential participants as the result of my actions.  I promise to honor my commitment, check and use official EYE Retreat email for communication frequently, and follow all expectations as outlined in all EYE Retreat policies, procedures, and practices.  Finally, I understand that the EYE Retreat Policy and Procedure Manual is available online at www.eyeretreat.org. *
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. *
Payment:  The cost to attend the EYE Retreat is FREE.  However, there is a REFUNDABLE commitment fee of $100.  If you attend the EYE Retreat, we will give you back your $100 the week of the EYE Retreat.   Parents/guardians or participants 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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