Summer Camp 2015
Summer Recreation Program Application Packet
Dear Parents:Thank you for your interest in the Glenwood’s Summer Recreation 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, March 27, 2015
_____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]
_____NON-REFUNDABLE $25.00 Application Fee
SUMMER 2015 PROGRAM INFORMATION-June 10, 2015- July 31, 2015
PROGRAM SUMMER DAYS/HOURS: Monday through Friday 8:00am- 2:00pm
PROGRAM BEGINS: Wednesday, June 10, 2015
PROGRAM NOT IN SESSION: June 29th – July 3rd
PROGRAM RESUMES: ______ July 6th ______
PROGRAM ENDS: July 31, 2015___
Ages for Camp: 6-17______
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 6 ½ week Summer Recreation Program for typical children is $285.00 per child.
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, then 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 deliveredto:
1). Felicia Houston, Ph.D., Licensed Psychologist
Director,Glenwood Summer Camp
Lakeview Center
150 Glenwood Lane
Birmingham, Alabama 35242
Office: 205-212-6716
E-mail:
2). Katrina Drake, BSM
Administrative Assistant, Community Education Programs
Lakeview Center
150 Glenwood Lane
Birmingham, Alabama 35242
Office: 205-212-6726
E-mail:
3). FAX: (205) 212-6739: ATTN: Katrina Drake
Summer Day Camp Application2015
SUMMER RECREATION PROGRAM CRITERIA FORM 2015
TYPICAL PEER
In order to serve as peer models, typical peersMUST 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).
______Be free of physical, medical, or mental impairments that would prevent successful participation in Summer Camp.
______Not pose a threat to the safety of themselves or others.
______Not require specialized medical care that must be provided by a Licensed Medical Professional.
Parent Signature Date
SUMMER RECREATION PROGRAM CRITERIA FORM 2015
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:
AllergiesAsthma 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
Lakeview Center
150 Glenwood Lane
Birmingham, Alabama 35242
(205) 212-6726
FAX (205) 212-6739
Permission to Observe Student at School for Glenwood’s Summer Recreation Program 2015-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 Recreation 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
______
GradeDate 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
**Please notify your child’s school that a staff member from Glenwood will be contacting the school to conduct an observation.
GLENWOOD’S SUMMER RECREATIONAL PROGRAM 2015
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 Camp by 2:00 PM each day that camp is in session. I also understand that I will not receive aftercare for my child during the entire time that he/she is attending Glenwood’s Summer Camp. I further acknowledge that if I am late picking up my child after normal camp hours between 8:00AM-2:00PM, I will be charged a late fee and payment will be due immediately upon late pick up.
A $10.00 fee will apply BEGINNING 2:10 PM for a child that is late being picked up. An Additional $1 every twominutes will apply after that.
______WILL NEED aftercare for my child: ______.
In selecting this choice, I understand that my child will be provided Aftercare from 2:00PM to 4:00PM each day that camp is in session. I also understand that if my child does not attend aftercare each day that it is offered, my fee will not be prorated, and I will notify Summer staff of my child’s absence. I further acknowledge that if I am late picking up my child after 4:00PM, I will be charged a late fee and payment will be due immediately upon late pick up. A $10.00 fee will apply BEGINNING 4:10 PM for a child that is late being picked up for aftercare. An Additional $1 every two minutes will apply after that.
______
Parent/guardian SignatureDate
1