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: ______