2024 Paddy Rossbach Youth Camp Registration This registration form is for Campers. Click here to download the Camp Counselor Application. "*" indicates required fields General Attendee InformationAttendee Name* First Last Attendee Email (Optional) Social Media Profiles (Optional)Add links to your social media profiles here.Would this be your first time attending Amputee Coalition's Youth Camp?* Yes No How many others have you attended?*Please type your answer in a whole number (Example: 3).What is your age?*Please type your age in whole numbers (Example: 14).Which of the following best represents how you think of yourself?* Lesbian or gay Straight, that is, not gay or lesbian Bisexual I use a different term Don’t know Prefer not to answer Please Indicate different term.* What sex were you assigned at birth, on your original birth certificate?* Female Male Don't know Prefer not to answer What is your current gender?* Female Male Transgender I use a different term Don’t know Prefer not to answer Please Indicate different term for gender.* What is your race?*Select all that apply. American Indian or Alaska Native Asian or Asian American Black or African American Native Hawaiian or other Pacific Islander White Prefer not to answer Prefer to self-describe Please indicate description for race.* What is your ethnicity?* Hispanic or Latino Not Hispanic or Latino Prefer not to answer What is your current zip code?*Limb Loss and/or Limb Difference InformationLL/LD Site*Select all that apply. Partial Foot - Left Below Knee - Left Above Knee - Left Hip - Left Partial Hand - Left Below Elbow - Left Above Elbow - Left Shoulder - Left Partial Foot - Right Below Knee - Right Above Knee - Right Hip - Right Partial Hand - Right Below Elbow - Right Above Elbow - Right Shoulder - Right LL/LD Cause*Select all that apply. Cancer Congenital Diabetes Disease Related Infection Trauma Type 1 Diabetes Type 2 Diabetes Vascular Other Unknown Please indicate other cause.* Year of initial amputation. (If applicable) Assistive Technology InformationDo you use a prosthesis?* Yes No Do you use an orthosis?* Yes No Do you use any assistive devices?*Select all that apply. Cane Crutches Scooter Walker Wheelchair Other Please indicate other assistive device.* Dietary InformationProvide any dietary information specific to the participant.*Travel Support Scholarship & Sponsorship InformationWill you need financial support for travel to attend camp?* Yes No Would you like to financially support travel for another youth to attend camp?* Yes No Essay and/or Video SubmissionPlease submit your one-page essay and/or video detailing why you would like to attend the YEP 2024 Paddy Rossbach Youth Camp.* Drop files here or Select files Max. file size: 50 MB. Emergency Contact InformationEmergency Contact/Legal Guardian #1* Relationship to Attendee* Email* Mobile/Cell*Emergency Contact/Legal Guardian #2* Relationship to Attendee* Email* Mobile/Cell*Likeness & Consent InformationConsent*I give the Amputee Coalition for America, permission to use my/my child's name, likeness, image, voice, story, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, quotes, print or online written documents, and the like, taken or made on behalf of Amputee Coalition activities. I agree that the Amputee Coalition ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with the Amputee Coalition’s mission. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation, etc for the use of such pictures, etc., and hereby release the Amputee Coalition and its agents and assigns from any and all claims that arise out of or are in any way connected with such use. I give my consent to the Amputee Coalition to use my name, story, and likeness to promote the Amputee Coalition’s mission and activities. Yes, I give my consent.
