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Camper Referral 2021 - Guardian

Parent/Guardian Form

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 Information

  • Child being referred for potential participation in Bay Cliff's 2021 summer therapy camp.
  • To be eligible for summer therapy camp, campers must be under the age of 18 for the entire summer.
  • Please enter a number from 1 to 15.
    Check all/any that apply.
  • School Information

    Check all school-based plans/support that the child currently receives.
    To be eligible for children's summer therapy camp, children must require skilled therapeutic intervention. Check any/all services that the child currently receives.
  • Describe/specify setting, therapy and service received.
    If 504, BSP or IEP plans were indicated - specify the services that the child receives in the school system.
  • Under what school-based category is the child eligible for specialized education services?
  • If 'Other' was indicated, please specify classroom setting.
  • Basic Medical

    Check all that apply. Some diagnoses with bring up an additional box below, requesting more specific information.
  • Please specify
  • Please specify
  • Please specify
  • Please specify
  • Please specify
  • Please specify
  • Please specify
  • Parent/Guardian Information

  • If applicable
  • **Notifications, questions and communications will be sent to this email address from Bay Cliff.**
  • 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).
  • 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.
  • This field is for validation purposes and should be left unchanged.
Save and Continue Later
Theresa Campana2021-01-22T14:57:35-05:00

N4175 County Road KCA, P.O. Box 310, Big Bay, MI 49808    |    baycliff@baycliff.org    |    (906) 345-9314    |    Fax: (906) 345-9890

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