Camper Referral 2021 – Teacher Camper Referral 2021 - Teacher For teachers (general education and special education) 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 information@baycliff.org Basic School InformationChild's Name* First Last Does this child have an end-of-year IEP?*NoYes2020/2021 Grade*ELA Grade LevelMath Grade LevelPercent (%) of day in General Education Setting*Current IEP, Progress Reports, BSP Drop files here or Accepted file types: jpg, png, pdf, . Upload current annual forms. We will request IEP from you if not attached to this form submission - as part of camper's application process to Bay Cliff Health Camp. We understand that you may prefer to fax, email or mail the IEP.Teacher InformationTeacher Name* First Last Email* Address (If interested in receiving future printed communications from Bay Cliff): 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 Phone*We will only phone you for questions specific to this child/this summer, after trying the email provided.Education Area*Where the referred child spends time with you. (Ex. General Education, Special Education, resource room, self-contained classroom)EligibilityBay Cliff Health Camp has developed a set of criteria to determine if children will be successful in our typical summer program. The entire criteria are available on our website, and several key indicators are included below. Check each box that is correct (aka the child 'is', 'does' or 'has') and add any notes necessary for clarification at the bottom. All Camper Criteria* 3-17 years of age Requires no more than minimal daily nursing care Breathes without ventilator Consistently communicates yes/no with everyone Needs skilled therapy intervention (OT/PT/Speech) Working on a life skill (Basic ADL [bathing, dressing, grooming] or more complex) Stable medications for behavior management (if applicable) No recent or major violence/aggression Regularly attends school for full day, 5 days/week Remains with group (no elopement) Tolerates variety of environments (loud, busy, bright, hot) Tolerates regular schedule (full day) Tolerates changes to schedule Notes (clarification):SkillsThis child is able to Follow familiar (routine) directions*UsuallySometimesRarelyThis child is able to follow 1+ step directions*UsuallySometimesRarelyThis child is able to get along with peers*UsuallySometimesRarelyThis child is able to play/interact with peers as expected*UsuallySometimesRarelyThis child is able to transition between activities in the school environment*UsuallySometimesRarelyThis child is able to transition with a group*UsuallySometimesRarelyThis child is able to participate in unstructured time with average/typical support*UsuallySometimesRarelyThis child is able to accept direction from more than one adult*UsuallySometimesRarelyDoes this child have 1-on-1 support for any part of their school day?*YesNoSpecify why/for what 1-on-1 services are provided:*Does this child require more assistance to complete tasks/activities compared to classmates?*NoYesWhat activities?*BehaviorCheck any of the following that apply to this child (if none, check none of the above):* Extreme anger reaction Gets in fights History of abuse History of depression History of suicidal thoughts/attempts Inappropriate touching of others Increased awareness of sex/sexuality Is impulsive Plays with/starts fires Prefers to be alone Requires a lot of attention Quick to anger None of the above Additional information on checked items:*When something unexpected happens, how does this child react?*When upset, how do you help this child calm?*What support does this child need during unstructured time (recess, play etc.)?*Is this child on medication for behavior management?*YesNoUnsureIf Yes, for how long?*Behavioral concerns for virtual camp setting? (individual therapy sessions, group events run by college-age camp staff etc.):*RecommendationsWhat recommendations do you have for Bay Cliff (for this child's success, for understanding and working with them, especially related to virtual programming)?Recommendations*OtherCAPTCHANameThis field is for validation purposes and should be left unchanged. Theresa Campana2021-01-22T14:56:33-05:00
