Camper Referral 2021 – Guardian Camper Referral 2021 - Guardian For parent/guardian of child being referred for potential participation in Bay Cliff Health Camp for summer 2021. Complete this form and submit, or you have the option (at the bottom of the form) to save and return later. All fields marked with * are mandatory. You will get an immediate notification of receipt (or link to access later). If you don't, please reach out to Bay Cliff Health Camp for support (906)345-9314 or jpinar@baycliff.org Basic InformationName of Minor* First Last Child being referred for potential participation in Bay Cliff's 2021 summer therapy camp.Gender*MaleFemaleBirthdate* MM DD YYYY To be eligible for summer therapy camp, campers must be under the age of 18 for the entire summer.Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County of Residence*Has this child participated in Summer Therapy Camp in the past?*YesNoHow many summers?*Please enter a number from 1 to 15.Most recent summer?*2020 (BCVC)201920182017201620152014201320122011Services received at Bay Cliff* Speech & Language Therapy Occupational Therapy Physical Therapy Vision Support Deaf/Hard of Hearing Support Check all/any that apply.School InformationSchool*Grade*Teacher (main)Current Plans* 504 Plan Behavior Support Plan (BSP) Individualized Education Plan (IEP) N/A (No school-based services) Check all school-based plans/support that the child currently receives.Community/Clinic-Based Services* Speech & Language Therapy Occupational Therapy Physical Therapy Other To be eligible for children's summer therapy camp, children must require skilled therapeutic intervention. Check any/all services that the child currently receives.More Information*Describe/specify setting, therapy and service received.School-Based Services* 1-on-1 Assistive Technology Counseling Educational Audiologist English as Second Language (ESL) Nursing Occupational Therapy (OT) Orientation & Mobility (O&M) Physical Therapy (PT) Social Work Speech & Language Therapy (Speech) Teacher for the Visually Impaired (TVI) Teacher for the Deaf/Hard of Hearing If 504, BSP or IEP plans were indicated - specify the services that the child receives in the school system.School Eligibility Category*Under what school-based category is the child eligible for specialized education services?Primary Classroom Setting*General Education (no support)General Education (with support)Resource RoomSpecial Education ClassroomSpecialized ProgramHomeschoolOtherOther*If 'Other' was indicated, please specify classroom setting.Basic MedicalPrimary Care Physician (PCP)*Physician Practice NameMedical Diagnosis/es Acquired Brain Injury Anxiety Attention Deficit (ADD/ADHD) Arthrogryposis Autism Spectrum Disorder (ASD) Chromosomal Syndrome DSM-V Diagnosis Cerebral Palsy Deafness/Hearing Loss Depression Down Syndrome/Trisomy 21 Dysphagia Epilepsy Fetal Alcohol Spectrum Disorder (FASD) Fragile X Syndrome Genetic Disorder Intellectual Disability Limb Loss (Congenital or Acquired) Muscular Dystrophy Obesity Prader-Willi Syndrome Specific Learning Disorder Spina Bifida Visual Impairment/Blindness Other Check all that apply. Some diagnoses with bring up an additional box below, requesting more specific information.Chromosomal Syndrome*Please specifyDSM-V Diagnosis*Please specifyDeafness/Hearing Loss*Please specifyGenetic Disorder*Please specifyMuscular Dystophy*Please specifyVisual Impairment/Blindness*Please specifyOther*Please specifyParent/Guardian Information(Primary Contact) Parent/Guardian Name* First Last Relationship to Child*Phone*Phone (secondary)If applicableEmail* **Notifications, questions and communications will be sent to this email address from Bay Cliff.**Mailing Address (if different than child) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code (Secondary Contact) Parent/Guardian Name First Last Relationship to childPhoneEmail Mailing Address (if different than child or primary contact) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 2021 ACCESSTo ensure the safety of our campers and staff, Bay Cliff's summer programming will be virtual in 2021. We are excited to once again prioritize therapy services, which will be offered -at high frequency- to camper/families. We are so excited to be able to offer therapy services again this summer! Bay Cliff is planning for 2 sessions of virtual camp, each running three weeks in duration. Each session will include individual therapy services (OT, PT, Speech - specific to the needs of each camper) which require an adult to be present, live group activities/events, facilitated time spent with peers, prerecorded activities (at your leisure) and a mailed to your door "camp in a box" activity. **Each family will indicate the session that works best for them, and slots will be filled in the order that applications are completed (this referral is the first step - see website or flyer for entire process). If space is available, Bay Cliff will offer second session slots to families who expressed interest in having their camper attend both (again, in the order they were completed/expressed). Do you foresee any challenges accessing our ALL-VIRTUAL platform?*To ensure safety and carryover, an adult will be required to attend/participate in all camper therapy sessions. Parents/guardians will select their child's sessions each week - at times that work for them (availability approximately 9am-9pm Monday through Friday, Saturdays as needed). Do you foresee any challenges with this model?Release of Information* Checking this box indicates you have read, understood and consent to the following.I, the parent/legal guardian of the aforementioned child, give permission for information and records about my child -including all health care providers and educational institutions- to be shared with Bay Cliff Health Camp. I also give permission for Bay Cliff personnel to contact me. CAPTCHAUntitledCommentsThis field is for validation purposes and should be left unchanged. Theresa Campana2021-01-22T14:57:35-05:00