The Children’s Institute of Pittsburgh

Memo

From: Amy Haid, director of Community Resources and Training

Date: 3/20/2014

Re: Camp Success Application Process

Thank you for your interest in Camp Success at The Children’s Institute of Pittsburgh!

To apply for Camp Success, please follow these steps:

1.  Print and fill out a Camp Success Application for each child.

2.  Return it via fax, email or regular mail to Amy Haid, director of Community Resources and Training by April 25, 2014.

3.  From April 28th –May 16th, the Camp Success coordinator will review all applications and call to speak with the person submitting the application. At that time, the coordinator will determine whether or not a particular child will or will not be accepted for placement within Camp Success and inform the parent/caregiver of that decision.

Camp Success is an accessible, inclusive, non-therapeutic, single-site summer day camp for children with and without disabilities. The camp accommodates children ages 6-12 with physical, sensory, emotional, behavioral and cognitive needs*. Often times, families struggle to find summer programs for their children because of barriers created by expense, transportation, exclusion of non-disabled siblings, and inability to accommodate children with behavioral problems.

Camp Success is a family enrichment program offered by The Children’s Institute of Pittsburgh. It serves Pittsburgh’s East End and surrounding communities.

*There are varying degrees of ability in these areas. During the application review process, the camp coordinator will determine if Camp Success is able to safely meet the special needs of each child applying for admittance.

Application for Camp Success 2014

Please complete application & return to Amy Haid by April 25, 2014

1405 Shady Avenue, Pittsburgh, PA 15217 * Fax 412.420.2143 *


Participant Information

Name: ______Nick-Name:______

Date of Birth: ______Age: ______

Address: ______Home Phone:______

______Cell Phone: ______

Parent/Guardian Name:______

Has your child attended Camp Success before? Yes/No

If Yes, when? ______

Medical Information

Primary Care Physician: ______Physician Phone #: ______

Diagnosis/Special Needs______

Are all of your child’s immunizations up to date? Yes/No

Does your child use medication? If so, what kind(s) and what are they used for?

______

______

Emergency Contact Information

Emergency Contact #1:______Relationship:______

Home Phone:______Cell:______Work:______

Does this contact have daytime transportation? (circle one) Yes No

Emergency Contact #2:______Relationship:______

Home Phone:______Cell:______Work:______

Contact #2 MUST have daytime transportation if Contact #1 Does Not

To ensure that we provide the best possible support, please identify any of the following that apply to your child:

* Behavioral Concerns

Disruptive Behaviors Yes  No

If yes, please explain (yelling, swearing, screaming, spitting, verbal threats, slamming doors/items, flops on floor, shuts down, runs off)

Aggressive Behaviors Yes  No

If yes, please explain (hitting, biting, kicking, scratching, pull hair, slam doors/items, throw items, head butting)

Self Injurious Behaviors Yes  No

If yes, please explain (scratching, pulling out own hair, bites self, hits self)

* Dietary Restrictions

* Vision/Hearing

* Mobility

* Allergies

* Bowel/Bladder

* Comprehension

* Communication

Please provide a description for any items checked above:

______

______

Application for Camp Success 2014

Please complete application & return to Amy Haid by April 25, 2014

1405 Shady Avenue, Pittsburgh, PA 15217 * Fax 412.420.2143 *

Please provide suggestions for supporting your child if a behavioral issue should arise:

______

______

Additional Information

Will your child need transportation? ______

Can you provide transportation if transportation is not provided? ______

What are your goals for your child to work toward at Camp Success? ______

______

Additional Comments/Concerns: ______

______

How did you hear about Camp Success?______

Are you a client of Project STAR at The Children’s Institute? Yes No

If NO, what organization recommended Camp Success to you?

______

Preferred Camp Session (Circle One)

June 25th-July 10th (except for July 4th) OR July 16th-July 30th

Will your child be able to come to all days of camp in their session? Yes No

Camp Success at The Children’s Institute respects the privacy and security of all information provided within this application/release. No information will be released to an outside entity with the exception that necessary medical information may be disclosed in order to ensure proper medical treatment in an emergency. This statement is provided to assure the parents/guardians of Camp Success participants that the information they provide is considered private and will not be shared with any other business or medical entity, except as stated above.

Parent/Guardian Signature: ______


Date Signed: ______