Camper Referral Form 2021
to be filled out by a social worker or other professional resource
Email *
Camper's name *
Parent's Name *
Camper's Address *
Phone Number of 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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