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This form can only be accessed with a custom link, which you clearly don’t have. If you are interested in applying for our Summer Youth Programs, please contact Youth Services Director Anahit LaBarre at alabarre@cocenter.org for more information.

Confirmation

Additional Info for Blank Contact

This form is pre-populated with data for Blank Contact. Are you completing this form on behalf of Blank?

Please Confirm:*

Yes
No

If you answered “No” above, Please contact Martin Becerra-Miranda at mbecerra@cocenter.org for more information.

Student Information

Check this box if this is an International Student

International

When International Student is checked, all address and phone number fields will change to International format.

Medical History

Local Primary Physician's Name

Medical Insurance Provider*

Preferred Hospital

Primary Cause of Blindness*

Does the student have any other disabilities and/or health issues?

Please check all that apply.

Hearing Loss
Diabetes
Traumatic Brain Injury
Uses Mobility/Support Device (other than a white cane)
Other (Please explain below.)

Explain any Other Disabilities and/or Health Problems

Explain any on-going treatments

Please list any allergies to medications

Medication	Symptoms of your allergic reactions

Please list any food allergies

Type of food	Symptoms of your allergic reactions

Other Allergies

Dietary Restrictions

Activity Restrictions

Explain Hospitalizations (last 5 years)

All Current Medications*

You may add additional medications by clicking the plus sign at the end of the list.

Medication Name	Dose	Frequency	Reason for taking	Date started	Self administered?	If No please explain

Will the student need to take any medications during Confidence Camp hours (9 a.m. to 3 p.m.)?

Yes
No

Medication to be taken during Confidence Camp hours (9 a.m. to 3 p.m.)*

You may add additional medications by clicking the plus sign at the end of the list.

Medication Name	Time to be Taken	Dosage	Special Instructions

Any additional information that will help us in working with this student?

Emergency Contacts

Emergency Contact #1

Emergency Contact #1 Name*

First Last

Emergency Contact #1 Address

Street Address City State ZIP Code

Emergency Contact #1 International Address

Street Address City State / Province / Region ZIP / Postal Code Country

Emergency Contact #1 Email*

If no email exists for this person, please use the following for this required field:

firstname.lastname@nomail.com

Substitute the actual first and last name of the person.

Emergency Contact #1 Cell Phone*

Emergency Contact #1 International Cell Phone*

Emergency Contact #1 Home Phone

Emergency Contact #1 International Home Phone

Emergency Contact #1 Work Phone

Emergency Contact #1 International Work Phone

Emergency Contact #2

Emergency Contact #2 Name*

First Last

Emergency Contact #2 Address

Same as Emergency Contact #1

Street Address City State ZIP Code

Emergency Contact #2 International Address

Same as Emergency Contact #1

Street Address City State / Province / Region ZIP / Postal Code Country

Emergency Contact #2 Email*

If no email exists for this person, please use the following for this required field:

firstname.lastname@nomail.com

Substitute the actual first and last name of the person.

Emergency Contact #2 Cell Phone*

Emergency Contact #2 International Cell Phone

Emergency Contact #2 Home Phone

Emergency Contact #2 International Home Phone

Emergency Contact #2 Work Phone

Emergency Contact #2 International Work Phone

Youth Medical History