Summer Day Program

2016 Application Packet/ASD

Dear Parents:
Thank you for your interest in Glenwood’s Summer Day Program,2016. We look forward to working with you and your child. In order to initiate the enrollment process, we need for you to complete the following:
RETURN BY Friday, Friday, April 8, 2016
______Signed Permission Form to observe student in his/her current school setting- [enclosed]
______Signed Program Criteria Form- [enclosed]
______Copy of insurance card
______Copy of Medicaid/All Kids card (if applicable)
______Current IEP
______ Autism Diagnosis and/or Notice and Eligibility Decision Regarding Special Education Services
______Completed Application Packet – [enclosed]
Tuition and Fees
The tuition associated with Glenwood’s SummerDay Program for children diagnosed with Autism Spectrum Disorder (ASD) can be billed to Medicaid or ALLKids.
Individuals who have a child with ASD and are interested in private pay please contact Shirley Kelley at or 205-212-6718or Valerie Anderson, Administrative Assistant at r 205-212-6726 for further information.
Supply/Recreation Fee: $285.00 per child. ***This is a SEPARATE fee from the Tuition for Summer Camp and is NOT covered by Medicaid or ALLKids. If your child is selected, the supply fee of $285.00 is due on the day of the intake meeting.
Once the above information is returned, we will schedule a time to observe your childin his/her school setting. Once this process has been completed, 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. Parents will be contacted by phone to schedule an intake meeting. You will receive a letter (via e-mail, fax, and regular mail) confirming the date and time for the intake meeting.
The above information may be e-mailed, faxed, mailed or delivered to:
Glenwood Inc., Summer Day Camp Application 2015
ATTN: Valerie Anderson
150 Glenwood Lane
Birmingham, Alabama 35242
Office line: 205-212-6726
E-mail:
FAX: (205) 212-6739
ATTN: Valerie Anderson
**APPLICATIONS ARE PROCESSED ON A FIRST COME FIRST SERVE BASIS. ALL FORMS MUST BE RETURNED TO BE CONSIDERED FOR PROCESSING.
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)

Glenwood, Inc.

GlenwoodSummer Day Camp 2016

APPLICATION/ASD

Child Case History Form

General Information

Child’s Name: ______Social Security:______

Date of Birth: ______

Address: ______City, State, Zip: ______

Home Phone: ______Cell Phone: ______

Mother’s Name: ______Mother’s Occupation: ______

Mother’s Age: ______Business Phone: ______

Father’s Name: ______Father’s Occupation: ______

Father’s Age: ______Business Phone: ______

Referred by: ______Referral Phone: ______

Child’s Legal Guardian: Marital Status of natural Parents:

Both Birth ParentsNot Married

Birth MotherMarried

Birth FatherSeparated

Adoptive ParentsDivorced

Department of Human ResourcesFather remarried

Other (please explain)Mother remarried

______

Brother’s & Sisters (include half-brothers/sister) Age Learning &/or Medical Problems

_________

______

____

When was your child diagnosed with an Autism Spectrum Disorder ______

Medical History

If applicable, please provide the approximate age at which your child 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).

Your child communicates by which of the following (√check all that apply)

CryingSentences

Playful Sounds Sign Language

Pointing with Index finger Picture Communication

Words

Phrases

How much of your child’s speech is understandable to you? Some ___Most___All___

How much of your child’s speech is understandable to others? Some ___Most___ All___

Does your child have any problems?

Understanding what someone says Yes No

Talking Yes No

Has your child’s hearing been tested Yes No

Was hearing loss reported? Yes No

If yes, who tested?

If yes, when tested?

If yes, what were the results?

Does your child have difficulty walking, running, or participating in other activities that require small or large muscle coordination? If yes, please describe:

Is your child a picky eater? If so, what foods will he/she eat?

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

Does your child have outburst or “meltdowns” due to anger, frustration, and/or sensory overload? If so, are there strategies that you have used that are helpful in correcting this behavior?

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:

**Attach additional pages if needed for further description of your child’s functioning.

Parent/Guardian SignatureDate

Glenwood, Inc.

The Autism and Behavioral Center

Program Criteria Form

Summer Camp 2016

Individual Served Name: ______Individual Served Number: ______

The Child and Adolescent Day Program provides goal-oriented services designed to maintain and/or improve the ability of an individual to function as independently as possible in the community. The individual can benefit from intervention with the expected outcomes being marked improvement in level of functioning and decrease in presenting signs and symptoms.

____ Individual must be between the ages of 5 ½ years and 17 years old.

____ Individual served must have a diagnosis of a mental disorder as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V); including SED/Behavior, Autism Spectrum Disorder and other related disorders (i.e., anxiety). The presence of a psychiatric diagnosis and/or Serious Emotional Disturbance (SED) will be determined by review of the following: Mental Health Treatment History, Mental Health Treatment needs, and current functioning in the areas of autonomy/basic living skill, family, school, and community. Final admission determination is based on observation of behavior, review of any current behavioral and/or diagnostic reports and the approval of the Director of the Day Program and/or Licensed Independent Practitioner.

____ Individual served must be experiencing deficits which impacts overall functioning in the home, school, and community environments. These deficits are to a degree that a highly structured day program would benefit the overall development, autonomy, functional independence, and Basic Living Skills of the individual.

____ Individual must not have any known life-threatening medical condition which warrants medical supervision.

____All individuals served in the Summer Camp MUST be toilet trained. No Exceptions.

____All individuals served must have independent transportation to and from the Summer Day site.

____ Individual can safely function in a group environmental setting with a minimum staff to child ratio of 1:3 or 1:4. Your child MUST not require a 1-to-1 aide.This will be determined by direct observation, interview, and other data gathering methods deemed appropriate and at the discretion of the Program Director or Day Program Coordinator.

____ Parent or Guardian must abide by the Parent Participation Contract which includes adherence to daily attendance, providing needed supplies and appropriate fees. No Exceptions.

____ Other eligibility criteria may apply as deemed appropriate and based on various situations that may not have been anticipated.

Per ______, LMET/LIP, this individual is approved for admission.

______

Parent/Guardian SignatureDate

______

MET SignatureDate

Glenwood, Inc.

The Autism and Behavioral Health Center

150 Glenwood Lane

Birmingham, Alabama 35242

(205) 212-6726

FAX (205) 212-6739

Permission to Observe Student at School for Summer Day Camp 2015 Enrollment

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 Camp. 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.

**PLEASE PRINT LEGIBLY.

Child’s Name

Grade

Classroom setting (Regular, special ed., resource etc.).

Name of School

School’s Telephone number

Teacher’s Name

Contact Person’s NAME AND PHONE NUMBER at School

(This person will be the individual that will be contacted to set up

the observation).

______

Parent’s SignatureDate

**Please notify your child’s school that a staff member from Glenwood will be contacting the school to conduct an observation.

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