Camper Referral 2021 – Guardian – Bay Cliff Health Camp

Basic Information

Name of Minor*

First Last

Child being referred for potential participation in Bay Cliff's 2021 summer therapy camp.

Gender*

Birthdate*

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 State ZIP Code

County of Residence*

Has this child participated in Summer Therapy Camp in the past?*

How many summers?*

Please enter a number from 1 to 15.

Most recent summer?*

Services received at Bay Cliff*

Speech & Language Therapy
Occupational Therapy
Physical Therapy
Vision Support
Deaf/Hard of Hearing Support

Check all/any that apply.

School Information

School*

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*

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*

Other*

If 'Other' was indicated, please specify classroom setting.

Basic Medical

Primary Care Physician (PCP)*

Physician Practice Name

Medical Diagnosis/es

Check all that apply. Some diagnoses with bring up an additional box below, requesting more specific information.

Chromosomal Syndrome*

Please specify

DSM-V Diagnosis*

Please specify

Deafness/Hearing Loss*

Please specify

Genetic Disorder*

Please specify

Muscular Dystophy*

Please specify

Visual Impairment/Blindness*

Please specify

Other*

Please specify

Parent/Guardian Information

(Primary Contact) Parent/Guardian Name*

First Last

Relationship to Child*

Phone*

Phone (secondary)

If applicable

Email*

**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 State ZIP Code

(Secondary Contact) Parent/Guardian Name

First Last

Relationship to child

Phone

Email

Mailing Address (if different than child or primary contact)

Street Address Address Line 2 City State ZIP Code

2021 ACCESS

To 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.

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Camper Referral 2021 - Guardian

Parent/Guardian Form