CAMP SIGN DARS-DRS 4900 North Lamar Blvd., Ste. 3427; Austin, Texas 78751 COUNSELOR IN TRAINING [CIT] IS A PROGRAM FOR DEVLEOPING LEADERSHIP SKILLS AND PREPARING BOYS AND GIRLS AGE 16 AND 17 TO BECOME FUTURE CAMP COUNSELORS AND LEADERS PARTICIPANTS ARE FORMER CAMPERS WHO MEET THE CIT PROGRAM CRITERIA ESTABLISHED BY THE CAMP SIGN COMMITTEE THE CIT PROGRAM CRITERIA ARE: 1. Must be deaf or hard of hearing 2. Must have attended Camp for the Deaf such as Camp Aspen, National Literacy & Literature Camp, Lion s Club Camp in recent years 3. Provide letter of recommendation from former counselors or Camp Director 4. Must meet Staffing Needs of Camp Qualifications: Minimum age 16 Maximum age- 17 Sign language skills/ability to communicate effectively with campers Types of Duties: Live in cabin with assigned campers and be responsible for them Keep track of the whereabouts of each camper in their cabin group Oversee cleaning of cabin Assist in assigned camper work responsibilities Help campers to understand and follow the camp rules Line up campers at the appropriate times Encourage campers to be orderly and quiet Encourage campers to learn and to develop new skills Be a role model to the camper A goal of Camp SIGN is to keep its programs focused on the camper s interests. Another goal for the camp is to involve young persons who are deaf or hard of hearing from throughout the state, regardless of their communication mode, for involvement in a learning environment. The philosophy of the camp is to provide an environment of acceptance and encouragement. The 2016 dates are Sunday, July 31- Saturday, August 6 t. Please understand that CITS will need to come on Saturday afternoon, July 30 t. Mail both completed CAMPER and CIT Applications along with the $35 application fee no later than June 20 th to Ann Horn Camp SIGN 2016 4900 N. Lamar Blvd., Suite 3427 Austin, Texas 78751 Page 1 of 7
Division for Rehabilitation Services Camp SIGN Application for Counselor-in-Training (CIT) Complete this application and return it to PO Box 12306 Austin, Texas 78711 If you need help or have questions, contact us at (512) 410-1387 or 1-866-568-5176 Fax: (512) 407-3299 Email: ann.horn@dars.state.tx.us www.dars.state.tx.us/dhhs CIT Applicant Information Print clearly. This form must be filled out by the applicant, not by a parent or teacher. Last name: First name: Birth date: Age: Enter X to select gender: Male Female Address: City: State: ZIP code: Email address: Pager: Home telephone: Work telephone: Cell phone: Enter X to select one from each of the following categories. T-shirt (adult size): S M L XL Status of hearing loss: Deaf Hard of hearing Hearing impaired Cochlear implant Method of communication: American Sign Language Signed Exact English Sign Language Oral Expressive skills Excellent Good Fair Poor Receptive skills Excellent Good Fair Poor XXL Education Information Enter X to select one: Still in high school Graduated with diploma Name of School City State Year of diploma Number of years attended Page 2 of 7
Employment Information List most recent position first. Include volunteer work and babysitting. Camp Experience Camp name, city, and state: Date Camper? CIT? Have you attended Camp SIGN before? Enter X to select. No As a camper As a CIT If so, what years did you attend? References List three people who know you and your abilities. Do not include family members. Name Relationship City, state Phone number Page 3 of 7
If you are accepted to be a CIT, which group would you prefer to work with? Enter 1 to select your first preference, and 2 to select your second preference. 8- and 9-year-olds 10- and 11-year-olds Activity If you are chosen to work with an activity coordinator, which group would you be interested in? Enter X to select all that apply Arts and crafts Archery Drama Karate Swimming Horseback riding Other (canoeing or sports) Write an essay of at least 150 words on why you want to become a CIT at Camp SIGN. Signature I certify that to the best of my knowledge the information given in this application is true. Signature: X Signature of parent or guardian: X Date: Date: Page 4 of 7
Complete this application and return it with the $35 application fee to PO Box 12306 Austin, Texas 78711 Division for Rehabilitation Services Camp SIGN Application for Campers If you need help or have questions, contact us at (512) 410-1387 Fax: (512) 407-3299 Email: ann.horn@dars.state.tx.us www.dars.state.tx.us/dhhs Applicant Information Last name: First name: Birth date: Age at camp date: Enter X to select gender: Male Female City: School: Grade: Enter X to select from each of the following categories. T-shirt (adult size): S M L XL XXL XXXL Ethnicity: Hispanic or Latino Not Hispanic or Not Latino Race (enter X to select all that apply) : American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Status of hearing loss: Deaf Hard of hearing Use Hearing Aids Cochlear implant Other (specify): Method of communication: American Sign Language (ASL) Signed Exact English (SEE) Sign Language Oral Other (specify): Parent or Guardian Information Enter X to select one. Parent Grandparent Guardian Last name: First name: Address: City: State: ZIP code: Home phone: Pager number or pager address: or Work phone: Email address: Cell phone: DARS3930 (03/12) A+ Camp SIGN Application for Campers Page 5 of 7
Name: Person to Contact in Case of Emergency Phone number: Relationship: Enter X to select all that apply. Diseases the applicant has had: Chicken pox German measles Measles Mumps Chronic or recurring medical conditions: Asthma Bleeding disorders Constipation Ear infection Fainting Nosebleeds Seizures Medical Information Known allergies: Animals Hay fever Insect stings Medications Pollen Plants Emotional or behavioral problems: Attention deficit Bedwetting Emotional disturbances Sleep disturbances Does the applicant take medicine? Yes No If yes, list medicines below: Does the applicant have behavior problems? Yes No If yes, enter X to select all that apply. Temper tantrums Hitting others Disobeying Uncooperativeness Attention deficit Note: Any camper who becomes a continual problem at the camp site will be sent home. DARS3930 (03/12) A+ Camp SIGN Application for Campers Page 6 of 7
Income Reporting List the average monthly income for each member in the household including children. Report gross income (amount before taxes, insurance, or deductions). You may choose not to provide the income information. If so, you must pay the full camp fee plus the application fee for your child. The amount due is listed in the preacceptance letter. If you do not wish to list the income information and agree to pay the full camp fee for this camper, enter or print your initials here:. 1. 2. 3. 4. 5. 6. 7. 8. First name Last name Social Security number* Monthly income *If any member of the household receives food stamps or Temporary Aid to Needy Families (TANF), list his or her case number and Social Security number. By signing this form, I affirm that Signature I am providing true and correct information regarding my child or foster child; I am applying to Camp SIGN for my child or foster child. I am submitting a nonrefundable application fee of $35.00. I understand that I will be charged and held responsible for any fees incurred by checks submitted with insufficient funds; I agree to release and hold harmless DHHS Camp SIGN from any damages arising out of personal injury or sickness caused by any accident occurring on or off the camp premises; I give permission to DHHS Camp SIGN officials to provide any and all medical attention to my child in the event of injury or sickness; I give permission for DHHS Camp SIGN to photograph, use, and release photographs of my child for the purpose of publicizing and promoting Camp SIGN; I understand that complete cooperation is expected from my child or foster child; and I understand that I am responsible for transportation to and from the camp for my child or foster child. Signature of parent or guardian: X Date: Printed name: DARS3930 (03/12) A+ Camp SIGN Application for Campers Page 7 of 7