CTB Oregon Referral Form 2019
Camp To Belong Oregon is an international program that reunites siblings that have been separated due to an out of home placement. This years Summer camp dates are: 6/23/19-6/28/19 and 8/11/19-8/16/19.

Please answer these questions completely and thoroughly, the camper referral information is critical to the selection process. A selection committee uses the information you provide to determine what campers will be the best fit for each session. We need you to provide these details to help us understand the needs and behaviors of the child(ren). The referral information listed in these questions is needed FOR EACH CHILD in the sibling group. Once you complete this for the first child, please start a new form for each additional child in the sibling group. By completing this referral, you agree to share all pertinent information with providers, parent, CASA, caseworker, etc so that all involved in the case of the child has the needed information. If at any time something changes with the child (needs/location/provider/etc) you must notify CTB immediately with the new information. This process is the FIRST STEP. Once our committee reviews the referrals you will get an email with further details. If the sibling group is excepted into a camp session you will then get information on how to submit an official application. Do you have questions? If so, please email Julea McKinney at registerctb@gmail.com

What is the full legal name of the child you are referring to Camp To Belong? *
Your answer
What is the birth date of the child? *
MM
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DD
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YYYY
Gender *
Your answer
What CITY, and COUNTY does the child currently reside in. *
Your answer
Has this child attended Camp to Belong in the past? *
What is the current custody status for the child? *
Name of person filling out this form, and your relation to the child. *
Your answer
Please note that you are not guaranteed your session of choice. However, we are interested in knowing if you have a scheduling conflict that would impact this child attending camp. *
NAME, EMAIL, and PHONE number of DHS caseworker for this child. If child is adopted or in biological home but has siblings that are in DHS custody please include sibling's caseworker name if known. *
Your answer
What is the full NAME, EMAIL address, and PHONE number for the person providing daily direct care to the child (parent, provider, care coordinator of residential facility, etc.) *
Your answer
Please list the full legal names of the other children that are part of this sibling group that will also be referred for camp this year (Make sure a separate referral is done for EACH child). *
Your answer
Do the siblings visit each other now, and if so, how often? How do they get along with each other? *
Your answer
Why do you think this sibling group would benefit from the camp experience? *
Your answer
Tell us why the siblings are not currently living together. *
Your answer
What are some of the child's favorite activities and/or hobbies? *
Your answer
Does this child ever need 1:1 supervision? If so, please explain. *
Your answer
Please check any that apply to the child. *
Required
How does this child get along with peers at school and youth in their current living situation? *
Your answer
Is there anything else that you feel like we should know about this child that wasn't covered in a previous question? *
Your answer
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