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SHEP 2024 DeafBlind Symposium Registration Form

Observers/SSP Camp Registration Form

All Campers Must be 18 years or older. You can pay by PayPal, Credit Card, Money Order, or Check. Online payment option is below.

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

Pay Observer/SSP camp Registration Fee Online

COST: $50.00 – SSP registration fee

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.**

** TWO SSPS ARE NEEDED FOR MOST DEAFBLIND INDIVIDUALS**

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

(###)

###

####

Is Transportation needed from airport or bus station? *

Yes

If yes, please provide all necessary information:

Which one best describes you?:

Hearing

Deaf

Hard-of-Hearing and can understand speech

Hard-of-Hearing but cannot understand speech

SSP Certification level

Level 1 SSP

Level 2 SSP

Level 3 SSP

Which is your dominant hand?

Right

Left

What is your preference of communication: *

Do you know how to use Protactile? *

Yes

Age Range *

18-40

40-60

Over 60

Do you want to SSP for a particular person? *

If yes and need transportation to, what is the person name?

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

If yes, what is this person name?

Do you have any special dietary needs? *

If any, please explain

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

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. Harassing Conduct Release: SHEP will not allow harassing conduct. It means after the other person tells you to stop bothering them, you will stop. I understand that if I am harassing, SHEP may ask me to leave the conference, and I will not get a refund or any part of a refund.

Is it OK to take pictures or videotapes of you at the DB conference/retreat? *

Yes

T-shirt Size: *

XXL-2X

XXL-3X

XXXL-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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First Name

Last Name

Email *

Thank you!

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