Summer Day Program 2016

Application Packet

Dear Parents:
Thank you for your interest in Glenwood’s Summer Day Program. We look forward to an exciting and fun- filled summer. In order to initiate the enrollment process, we need you to complete the following:
RETURN BY Friday, April 8, 2016
_____Completed Enrollment Packet – [enclosed]
_____Signed Program Criteria Form – [enclosed]
_____Signed Permission Form to observe student in his/her current school setting- [enclosed]
_____Aftercare Form—[enclosed]
SUMMER 2016 PROGRAM INFORMATION-June 1, 2016- July 29, 2016
PROGRAM SUMMER DAYS/HOURS: Monday through Friday 8:00am- 2:00pm
PROGRAM BEGINS: Wednesday, June 1, 2016
PROGRAM NOT IN SESSION: July 4th – July 8th
PROGRAM RESUMES: ______ July 11th ______
PROGRAM ENDS: July 29, 2016___
Ages for Summer Program: 6- to 17-years old_
4 Classrooms
·  Classroom 1: Ages 6-8
·  Classroom 2: Ages 9-11
·  Classroom 3: Ages 12-14
·  Classroom 4: Ages 15-17 (Transition/work skills)
**Tuition and Fees
The tuition fee associated with the Glenwood’s 7 ½ week Summer Recreation Program for typical children is $285.00 per child. There is an additional Supply/Recreation Fee of $285.00 per child. ***This is a SEPARATE fee from the Tuition for Summer Camp fee. The Summer Day Program hours are from 8:00AM – 2:00PM. If you require before- and/or after-care (7:00AM – 8:00AM and 2:00PM – 4:00PM), an additional fee of $50.00 will be charged.
Once the above information is returned, a determination will be made regarding acceptance and enrollment. We will notify you if your child is accepted. If a space is offered, you will have one week to accept or decline the slot. If there is no response within the week deadline, your child’s name will be removed from the list of applicants. If accepted, an intake meeting will be scheduled. The Intake will involve gathering other required information to satisfy Glenwood’s Policy and Procedures as well as other Agency requirements.
The requested information may be e-mailed, mailed, faxed, or delivered to:
1). Shirley C. Kelley, M.A.
Director of Community Education Programs
Quarterback Center
150 Glenwood Lane
Birmingham, Alabama 35242
Office: 205-212-6718
E-mail:
2). Valerie Anderson, Administrative Assistant
Community Education Programs
Quarterback Center
150 Glenwood Lane
Birmingham, Alabama 35242
Office: 205-212-6726
E-mail:
3). FAX: (205) 212-6739: ATTN: Valerie Anderson
Summer Day Camp Application 2016

SUMMER DAY PROGRAM CRITERIA FORM 2016

TYPICAL PEER

In order to serve as peer models, typical peers MUST exhibit the following characteristics:

**Please review and initial each criterion in the space provided. Someone from Glenwood will observe your child in his/her school environment as well as speak with his/her teacher concerning the criterion below.

______Age-appropriate (or better) social skills/manners

______Age-appropriate (or better) communication skills

______Age-appropriate (or better) self-help/independent living skills

______Age–appropriate (or better) imaginative play/interaction skills

______Age-appropriate activity level

______Age-appropriate (or better) classroom skills (such as listen/attend to the teacher and model skills such as raising his/her hand; demonstrate appropriate time on task and task completion skills for age-level; remain seated during group/work activities for age-appropriate time periods)

______Has NOT required a specific behavior management plan in the school setting and/or discipline reports within the last school year.

______Willingness and ability to model expected behaviors/skills.

______Cooperation with program/classroom rules and willingness to actively participate in scheduled activities (**No consistent reports from your child’s school of oppositional and/or defiant behaviors towards adults and/or peers).

______Tolerance/kindness demonstrated in daily interactions with children of differing abilities.

______Be able to fully participate in the routines and activities of Camp and are willing to participate in daily, structured activities (e.g., not being consistently negative or refusal to participate in activities).

______Due to our program needs, typically developing students must be without behavioral, psychological, neurological, medical, or physical disabilities

______Does not pose a threat to the safety of selves or others.

______Do not require specialized medical care that must be provided by a Licensed Medical Professional.

Parent Signature Date


SUMMER DAY PROGRAM 2016

TYPICAL PEER APPLICATION

General Information

Child’s Name: Date of Birth:

Address: City, State, Zip:

Home Phone: Child’s Social Security #______

Mother’s Name: Mother’s Occupation:

Mother’s Business Phone: Cell Phone:

Father’s Name: Father’s Occupation:

Father’s Business Phone: Cell Phone:

Medical History

If applicable, please check if your child has had the following illnesses/conditions:

Allergies Asthma Chicken Pox

Colds Sleep Problems Croup

Dizziness Draining Ear Ear Infections

Encephalitis Feeding Problems Headaches

High Fever Influenza Growth Problems

Measles Meningitis Mumps

Pneumonia Seizures Sinusitis

Tonsillitis Other

Does your child have a specific medical diagnosis? A significant health problem?

______

Is your child taking any medications? If yes please list the name of the medication, the dose, and the frequency. ______

Please describe all allergies your child has (medication, food, environmental). ______

Is your child on any special diet? Does he/she take any nutritional supplements? If yes, please describe.

How would you describe your child?

□ Usually very active

□ Active sometimes, but can play quietly

□ Usually not active

□ Usually happy

□ Can be moody

□ Demands attention

□ Aggressive towards self or others

□ Difficulty attending to activities

□ Prefers motor activities

□ Prefers sit-down activities

Please describe your child’s play/social skills? ______

What does your child enjoy doing in his/her free time? ______

______

What are your child’s special interests, likes, and dislikes? What rewards or motivates your child? ______

Other pertinent information:


Glenwood, Inc.

The Autism and Behavioral Health Center

Quarterback Center

150 Glenwood Lane

Birmingham, Alabama 35242

(205) 212-6726

FAX (205) 212-6739

Permission to Observe Student at School for Glenwood’s Summer Day Program 2016-Typical Peer

I hereby give the staff of Glenwood, Inc., the Autism and Behavioral Health Center, permission to observe my son/daughter in his/her current school setting as part of the application process for Glenwood’s Summer Day Program. The Program Coordinator and/or designee will contact the school to make an appointment with my child’s teacher and I will be notified of the date and time of the appointment.

______

Child’s Name

______

Grade Date of Birth

______

Name of School

______

School System/Telephone number

______

Contact Person’s NAME AND PHONE NUMBER at School

______

Name of General Education Teacher—If different from Contact Person

______

Parent’s Signature

GLENWOOD’S SUMMER DAY PROGRAM 2016

AFTERCARE FORM

I, ______,

Parent/guardian Signature

______WILL NOT need aftercare for my child: ______.

In selecting this choice, I understand that my child must be picked up from the Summer Day Program by 2:00 PM each day that the program is in session. I further acknowledge that if I am late picking up my child after normal camp hours between 8:00 AM-2:00 PM, I will be charged a late fee of $10.00. The fee will be applied BEGINNING at 2:15 PM. An Additional $1 fee will be applied every fifteen minutes after 2:15 PM. I will notify Summer Day Program staff if I will be late picking up my child.

______WILL NEED aftercare for my child: ______.

In selecting this choice, I understand that my child will be provided Aftercare from 2:00 PM to 4:00 PM each day that the Summer Day Program is in session. I further acknowledge that if I pick up my child after 4:00 PM, I will be charged a late fee of $10.00. The fee will be applied BEGINNING at 4:15 PM. An Additional $1 fee will be applied every fifteen minutes after 4:15 PM. I will contact a Summer Day Program staff member if and when I know I will be late in picking up my child.

______

Parent/guardian Signature Date

1