Camper Referral Form
This form is to be filled out by a social worker or other professional resource. Campers must meet the criteria to attend camp. They also must complete the second grade and can not have attended Middle/High School prior to attending camp. Camp will be held August 1-6, 2022 at Hashawha Environmental Center in Carroll County. Transportation is provided to and from camp. There is no cost for the families but we do ask that if your agency has funding to send children to camp or other extra curricular activities you consider sending funds to help support our program. You can reach the Camp Director, Darlene Waldt, at 443-799-1009 or if you have any questions or concerns.
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Email *
Camper's name *
What grade is the Camper attending for the 2021-2022 school year? Please Note: We do not accept children that are currently attending Middle School/High School. *
Is the camper Male or Female? *
Parent's Name *
Camper's Address *
Phone Number of Parent *
Email Address for Parent *
Referring Resource's Name *
Referrer's Job Title *
Referrer's Organization *
Referrer's Mailing Address *
Referrer's Phone Number *
In your professional opinion, does this child have a history or suspected history of child abuse and/or neglect? *
Are there any specific behaviors or concerns that our staff should be aware of? *
Why do you feel that the child could benefit from Camp Opportunity? *
Are there any family issues at this time that we should be aware of? *
How do you feel these issues should be addressed should it come up at camp? *
Does the child have a mental health diagnosis that we should be aware of? *
Does the child have any emotional or physiological issues that we should be aware of? *
How does the child respond to discipline or being redirected? *
What types of strategies do you suggest when working with this child? *
Do you know of any allergies (including food) or special medical needs? *
Are there specific guidelines for these needs?
Please provide the name and phone number of the child’s primary care physician. *
Please provide the name and phone number of the child’s emergency contact. *
As a professional resource for this child do you verify that the information that you have provided is factual  based on your knowledge of the child? By answering yes to this question, you are ensuring that the information that you have provided is truthful and  are confirming to the best of your ability that the child meets the criteria for our program. *
Entering your name below confirms that you have answered the preceding questions to the best of your ability. *
A copy of your responses will be emailed to the address you provided.
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