VIP Summer Registration Form and Questionnaire 
Please complete all questions to the best of your ability.  This information helps us provide the best experience for program participants and collects information crucial for grants.
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Participant's Name *
Which Camp Will You Attend? *
Complete Address *
Phone Number (Home or Mobile) *
Email *
Participants Date of Birth *
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Gender *
Height *
Weight *
T-Shirt Size *
Do you identify as Lesbian, Gay, Bisexual, Transgender and/or Queer? *
Race and Ethnicity *
PARENT OR LEGAL GUARDIAN INFORMATION 
(If participant is a minor or legally incapacitated)
Parent or Guardian Name *
Relationship to Program Participant *
Address (If different from above)
Phone Number (Home or Mobile) *
Email Address *
EMERGENCY CONTACT IN COLORADO
Name *
Phone Number (Home or Mobile) *
Relationship to Participant *
EMERGENCY CONTACT AT HOME
Name *
Phone Number (Home or Mobile) *
Relationship to Participant *
VISION INFORMATION
Important: Our arrangement with our sponsors is that we need to keep documentation of your vision loss on file.  Please provide us with a 3rd party verification (Doctor, Rehab Counselor, Etc.)
Please describe your visual impairment including level of sight, if any. *
When did your vision loss begin? 
(Birth, particular year or age)
 *
What was the cause of your vision loss? *
Do you use a guide dog? *
If you use a guide dog, will the dog come to Vail with you? *
MEDICAL INFORMATION
Are you currently taking any medications? *
If YES, please list all, including over the counter medications.  Please also indicate if these medications affect you at high altitude and/or cause dehydration.
Have you had surgery in the last six months? *
If YES, please describe the surgery.
Do you have allergies? *
If YES, please list your allergies.
Do you carry an EpiPen? *
PLEASE INDICATE YES OR NO TO EACH QUESTION BELOW.  IF YES, PLEASE DESCRIBE TYPE AND SEVERITY
Are you currently under a doctor's care for ANY CONDITION (other than vision loss)? *
If YES, please explain.
Traumatic Brain Injury? *
If YES, please explain.
Post-Traumatic Stress? *
If YES, please explain.
History of seizures or seizure disorder? *
If YES, please explain.  Include date of most recent seizure and how often they occur.
Deaf or hard of hearing? *
If YES, please explain.
Limited range of motion in any limbs? *
If YES, please explain.
Difficulty with balance? *
If YES, please explain.
Wear any sort of spinal stabilization? *
If YES, please explain.
Any type of paralysis? *
If YES, please explain.
Sensitivity to hot or cold? *
If YES, please explain.
Difficulty speaking or communicating? *
If YES, please explain.
Difficulty remembering or following directions? *
If YES, please explain.
Emotional and/or behavioral concerns we should know about? *
If YES, please explain.
Personal care or independence concerns? *
If YES, please explain.
Cognitive or developmental delay? *
If YES, please explain.
Heart/Cardiac condition? *
If YES, please explain.
Respiratory condition? *
If YES, please explain.
Are you allergic to anything? *
If YES, please explain.
Are you able to walk on your own, without the assistance of other people or medical devices? *
If NO please explain.
Do you need to limit your activities for any reason? *
If YES, please explain.
Please list any other medical conditions, concerns or instructions not mentioned above (i.e., bone disease, easily fatigued, weakened immune system, etc.)
PARTICIPATION INFORMATION
Please indicate which activities you've previously participated in and at what level you are. *
Beginner
Intermediate
Advanced
Hiking
Stand Up Paddle Boarding
Rock Climbing
Horseback Riding
River Rafting - Float Trip
Archery
None of these activities
What are your fears, if any, about any of these activities? *
What are your likes/dislikes? *
What are you recreation goals? *
What other physical activities do you participate in? *
Will a caregiver be accompanying you? *
Would your caregiver be willing to carpool other kids and/or chaperone other kids in the evening and mornings? *
Yes
No
Drive Carpool
Chaperone
If YES, please provide name and contact information.
Please provide any additional information that will help us create a successful experience for you.
Where did you hear about Foresight Adventure Guides for the Blind?
A sensitive question but funders are all about diversity, equity and inclusion nowadays.  Most of our funders want to know, generally, the income level of our participants to be sure we are being equitable and inclusive, especially since we pride ourselves in offering our programs at no cost.  We will NOT reveal your individual income information - just generally as a group:  "X" percent of our VIP's reported income of "$20,000-$50,000, etc.  We appreciate you answering this question but understand for some it may be uncomfortable.  If that's the case please indicate you "prefer not to answer."  
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AKNOWLEDGEMENT
I certify that the information provided in this form is true and correct to the best of my knowledge
Name *
If the participant is under 18 or legally incapacitated, please complete the final few questions.
Parent/Legal Guardian's Name
Relationship to Participant
Today's Date *
MM
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Thank you for taking the time to complete this questionnaire.  Please contact us if you have any questions.
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