Michigan Community Services for the Blind and Physically Challenged

Dear Friends 
I want to let you know that Michigan Community Services for the Blind and Physically Challenged will be joining the Holly SDA Church for their Family camp this fall. Family camp will be held at Camp AuSable in Grayling Michigan 
The event will be November 17 to 19, 2023.
Blind campers will need sighted guides.
So we need both blind campers and sighted guides to sign up.
Winter camp for the Blind will be January 28 to February 4 , 2024. This camp will also be at Camp AuSable in Grayling Michigan 
We also need Blind Campers and Sighted Guides to sign up .
Some of the activities at Winter Camp will be tubing down the hill at Hansen Hills ,Swimming in a indoor pool of course, skiing, snowmobiling, and sleigh rides with horse drawn sleighs , Hay Rides with horse drawn wagons,and horse and buggies rides with the Amish .
In addition to these activities we will have Pastor Fred Calkins sharing the morning and evening worship at Winter Camp.
Those interested in coming contact Larry Hubbell 
Phone 248-459-3165
Email elhubbell7@gmail.com
Website miblindcamps.org 
Thank you 
Sincerely 
Larry Hubbell 
Camp Director

MICHIGAN  WINTER CAMP January 28 to   February 4 , 2024

Camper’s Name______________________________________________________

Mailing address ______________________________________________________

Number & Street                                 City                                         State                  Zip

Cell Phone Number _______ (          ) ____________________________________

❏Male                       ❏Female              Birthdate ________________________ Age _________

Legally blind: Central visual acuity that does not exceed 20/200 in the better eye with correcting lens; field of vision no greater than 20 degrees in it’s widest angle (visual acuity of 20/200 means that a person can see at a distance of 20 feet what one with “normal” sight can see at 200 feet.)

❏Legally              ❏Totally              ❏Has seeing-eye dog

Emergency Contact Name:_____________________________________________________________

Phone (_____) ______ - _________          Cell phone (_____) ______ - _________

T-SHIRT size (men's sizes)      ❏S     ❏M      ❏L    ❏XL    ❏2XL    ❏3XL

HEALTH HISTORY

❏Diabetes   ❏Seizures (date & cause of last one)   ___________________________________

❏Bed wetter (Bring Pull-ups/Depends/or equivalent for the entire week.)

ALLERGIES

❏Insect stings                ❏Penicillin           ❏Other drugs ____________________________

Mail Application and $50 fee to:

Michigan Community 

Services for the Blind

812 Academy Rd

Holly, MI 48442

248-634-4379

248-459-3165

MEDICAL INSURANCE          Take Medical card to camp.

RESTRICTIONS Michigan Community Services for the Blind and Physically Challenged ARE NOT staffed to care for campers with mental and/or physical problems that require professional staff. Campers must be able to walk on their own and care for personal needs. Otherwise campers are expected to provide, and cover the costs for, sighted guides. Those with multiple disabilities may not be eligible.  Persons who cannot control their bowels should not attend camp.

❏ Camper can perform daily hygiene activities unassisted (dress, comb hair, etc.).

❏ Camper can perform daily personal activities unassisted (eating, restroom, etc.).

MEDICATIONS Nurses need to know prescription medications they are dispensing. 

MUST bring medicines to camp in original containers. List ONLY PRESCRIPTION MEDS.

Prescription meds _______________________ Dosage _____________________

Prescription meds _______________________ Dosage _____________________

Prescription meds _______________________ Dosage _____________________

Prescription meds _______________________ Dosage _____________________

❏ I have listed additional Prescription meds on a separate paper.

IMMUNIZATION (Required)

Campers MUST have had a tetanus shot within the past 10 years. Last tetanus date __________

OVER-THE-COUNTER MEDICATIONS

MEDICAL EXAMINATION (Required)

This examination should be performed not more than 12 months before arrival at camp for determining fitness to engage in strenuous activities.

Height _______________       Weight ______________       Blood pressure ________________

Diagnosis _____________________________________________________________________________

List Restrictions (if any) _____________________________________________________________________________

I have examined the person herein described and have reviewed their health history. It is my opinion that they are physically able to engage in camp activities, except as noted above.

Licensed Primary Care Medical Professional 

Printed name ___________________________________ Title _________________________

Address______________________________________________________________________

Phone _________________________________________ Date _________________________

CONSENT & RELEASE

PLEASE READ CAREFULLY and sign below. IT IS MANDATORY THAT THIS BE SIGNED.Your application will be returned if it is NOT signed.

TRANSPORTATION TO AND FROM CAMP IS YOUR RESPONSIBILITY!

★I release the camp, its management, Michigan Community Services for the Blind and Physically Challenged from liability in case of accident or illness and do further indemnify and hold harmless such entities and persons from such claim.

★In case of a medical emergency, I hereby give permission to the physician selected by the camp director or health care personnel to secure proper treatment and/or to hospitalize as deemed necessary.

★All information is correct to the best of my knowledge.

★I agree to cooperate with the camp staff.

★I agree not to engage in illegal or prohibited activities.

★I understand and agree to abide by the restrictions placed on my camp activities.

★I understand that smoking, use of illegal drugs, alcohol, tobacco products, firearms, explosives, and sexual promiscuity between male and female, male and male, or female and female, are not permitted at camp.

★Michigan Community Services for the Blind and Physically Challenged has the right to reject or send a camper home, at the camper’s or caregiver’s expense.

★I hereby consent and authorize Michigan Community Services for the Blind and Physically Challenged or it’s assignees, to use my name as well as my photos, videos, audio recordings and other information for the purpose of news releases, advertising, publicity, publication, or distribution in any manner whatsoever. I further consent to such use in their present form and to any changes, alterations, or additions there to.

I hereby release Michigan Community Services for the Blind and Physically Challenged from all liability in connection with all such uses and agree to indemnify and hold them harmless from any and all claims that may arise from or be related to the use of my image/photograph. I grant this privilege to Michigan Community Services for the Blind and Physically Challenged without compensation or payment of any kind.

Signature __________________________________                Date __________________

I am the ❏ Parent ❏ Legal Guardian ❏ Adult Camper ❏ Caregiver

(All campers under 18 years old must have parent’s or guardian’s signature.)