Camp Woodbine Registration

provided by The Guilt Free Shop

Features Applicant Information First Name: Last Name: Address: City: State: Zip Code (00000): Date of Birth (MM/DD/YYYY):
Is this Child: MaleFemale Does this Child Use (Check all that apply): Cochlear Implant: Hearing Aids: ASL/Sign Language: Siblings Attending(Full Name and Age): T-Shirt Size for Camp Attendees(Please indicate number desired): Youth Small: Youth Meduim: Youth Large: Adult Small: Adult Medium: Adult Large: Parent/Guardian First Name: Parent/Guardian Last Name: Parent/Guardian First Name: Parent/Guardian Last Name: Phone #: Email: Yes, as a parent/guardian I would be interested in attending an educational workshop on: Family Dynamics Assistive Listening Technology Developing a positive relationship with medical professionals Resources for CI and hearing aid users I would like to volunteer as:

Carolina Ear and Hearing
(919) 876-4327

Please contact Carolina Ear and Hearing Clinic if you have any questions: (919) 876-4327

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