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SHEP 2024 DeafBlind Symposium Registration Form

DB Camper Registration Form

All Campers Must be 18 years or older. You can pay by PayPal, Credit Card, Money Order, or Check. Payment option will be at end of form.

SHEP 2024 DeafBlind Symposium

WHEN: Thursday, October 10, 2024 at 3:00pm until Sunday, October 13, 2024 at 12:00pm

WHERE: Spring Valley Ranch – 42301 County Road 510, Eucha, OK 74342

COST: $250.00 - DeafBlind/Observer Campers

Pay Camper Registration Fee Online

THEME: Happy Days!

TRANSPORTATION: If transportation needed from airport or bus station, please

provide all necessary information

DB RETREAT INCLUDES: Welcome bags, t-shirt, room stay of three nights, meals, socializing, fun activities-games, crafts, one-on-one techs help if needed and costume party. **Party theme: Rocking happy in 50s or 60s costume styles.**

SPACE IS LIMITED TO 30 CAMPERS. Registration deadline will be on September 10, 2024, 30 days before Camp date. A confirmation letter with more information will be sent at a later date.

IMPORTANT ATTENTION: If you are paying by money order, payment must be in post marked no later than September 10, 2024.

You can mail check or money order to: SHEP, PO BOX 10495, Oklahoma City, OK 73140

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

Gender *

Date of Birth

YYYY

Emergency Contract Name

First Name

Last Name

Emergency Number

(###)

###

####

Age Range *

18-40

40-60

Over 60

My Vision is best described as: *

Tunnel Vision/Usher Syndrome

Close Vision

Blind

My hearing is best described as: *

Deaf

Hard of Hearing and can understand speech

Hard of hearing but cannot understand speech

My SSP preference is: *

Deaf SSP is possible

Hearing SSP

Does not Matter

Will you bring your own SSP? *

SSP Name if you are bringing SSP

Name of Roommate *

Who do you want to be your roommate? You can list 2 people to share a room with you, but only one will get picked. Your roommate must list your name on their form, too. If you do not list any roommates on this form, we will do our best to match you with someone else to share the room with you. There will only be two people to a room.

Do you use a wheelchair?

Will you bring a guide dog?

Will you be willing to share room with a person who has a guide dog? *

Are you a smoker? *

Will you be willing to share a room with a smoker? *

List the name of any SSP(s) you prefer not to be matched with:

This year, we will make a roster of people at the Conference. We will give out copies of the roster in the packets at the Conference. Your name will be printed on the Conference roster in the packet. *

Name only listed

Name and address listed

Name, address, and VP/TTY/V number listed

Name and email

I need a SSP: *

For all or most activities

For night-time activities only

I do not need a SSP

What is your preference of communication?: *

ASL

PSE

Sign English only

Fingerspelling only

Speech/Oral

Which do you prefer using?: *

Platform Interpreter

Close Vision Interpreter

Tactile (touch) Interpreter

Other preferred communication

Do you require a special diet?

Read and agree to terms below. Type Name in box to consent. *

SHEP Deaf-Blind Conference Release Form Contract Releasing Liability: I am responsible if: • I become sick, hurt or die at the Conference. • Some of my belongings (suitcase, bags, money, etc.) are lost or damaged or missing at the Conference. • I am responsible if I become sick, hurt, or lose anything when I travel to the Conference or travel home again. I will not hold Sight-Hearing Encouragement Program (S.H.E.P.) responsible if these things happen. SHEP is not responsible. The Sequoyah Lodge is not responsible, either. Contract Releasing Liability: I, the undersigned, hereby assume all risks of personal injury, illness, death and damage to and loss of property. I expressly waive and release Sight-Hearing Encouragement Program (S.H.E.P.), their trustees, employees, agents, and other conference participants from any and all liability, claims, demands and causes of action whatsoever which arise from or in connection with my participation in the conference, including traveling to or from the conference, for personal injury, illness, death, or damage to or loss of property. Public Relation (Please check one: Sometimes TV or newspaper reporters will come to the conference to write a story and take pictures. Other times, photographers come to the conference to take pictures. SHEP use the pictures to inform people about Deaf-Blindness, and to help raise money for the conference.

Is it OK to take pictures or videotapes of you at the Conference? *

Yes

T-shirt Size: *

XXL-2X

XXXL-3X

XXXXL-4X

Payment Method *

Visa

MasterCard

American Express

PayPal

Check

Money Order

Thank you! We will send a confirmation letter or email to you when we process your registration. For any questions, contact us at humanresources@shep-ok.org

405 730-8182 info@shep-ok.org

Hours

Mon 8am - 4pm

Tue 8am - 4pm

Wed 8am- 4pm

Thu 8am - 4pm

Fri 8am- 4pm

Sat Closed

Sun Closed

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Email *

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