Pathway to Hope Family Application Form - Anchor Point Family Network

Dear Prospective Camp Family,

Thank you so much for your interest in our Pathway to Hope Family Camp. The ultimate goal of our camp is to help families and children construct meaningful connections and deeper relationships. This will allow the children to not only survive but to ultimately thrive in life!

Please complete the following chart by indicating, in order of preference, which camp your family would like to attend as well as the application on the subsequent pages. Upon completion please email, fax, or mail your application back to Debbie Simmons as well as pay the non-refundable $50 application fee (this can be paid on our website by clicking donate now. Make a note on the payment that it is for the PTH application fee). If selected this fee will be applied to the overall camp fee.

Please contact me should you have any questions. We look forward to working with you and your family!

Debbie Simmons
CEO/Founder
Anchor Point
832.632.1221
debbie@anchorpont.us

SUMMER 2025

Date: July 21-25 Day Camp

Time: 8:30 – 4:00 pm | 7/25 ends at 5pm

Pre Camp: July 20 | 2:00 – 6:00pm

Home Visit: TBD

Payment: $750 for family of 4 + $100 per child after

Expectations: Attend all scheduled camp dates as well as corresponding sessions when applicable

Family Camp Application

Will your target child be between the ages of 5-13 on July 1, 2025?

Yes

Will your target child have been living within your home for one year?

Yes

Are you and your family willing to be photographed and videotaped?

Yes

Are both parents willing to complete a criminal background check?

Yes

Parent's Information

Mother's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

License #(Required)

Date of Birth(Required)

Degree

Occupation

Work Schedule

Travel

Yes

Tshirt Size(Required)

Food Allergies, Sensitivities, Allergies(Required)

Father's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

License #(Required)

Date of Birth(Required)

Degree

Occupation

Work Schedule

Travel

Yes

Tshirt Size(Required)

Food Allergies, Sensitivities, Allergies(Required)

Child Information

How many children do you have?(Required)

Please enter a number from 1 to 6.

Target Child Information(Required)

First Last

Date of birth

Current Age(Required)

Tshirt Size(Required)

Food Allergies, Sensitivities, Allergies(Required)

Sibling Information

Sibling 1(Required)

First Last

Date of Birth(Required)

Current Age(Required)

Tshirt Size(Required)

Food Allergies, Sensitivities, Allergies(Required)

Sibling 2(Required)

First Last

Date of Birth(Required)

Sibling 2 Date of Birth

Current Age(Required)

Tshirt Size(Required)

Sibling 2 Tshirt Size

Food Allergies, Sensitivities, Allergies(Required)

Sibling 2 Food Allergies

Sibling 3(Required)

First Last

Date of Birth(Required)

Sibling 3 Date of Birth

Current Age(Required)

Tshirt Size(Required)

Sibling 3 Tshirt Size

Food Allergies, Sensitivities, Allergies(Required)

Sibling 3 Food Allergies

Sibling 4(Required)

First Last

Date of Birth(Required)

Sibling 4 Date of Birth

Current Age(Required)

Tshirt Size(Required)

Sibling 4 Tshirt Size

Food Allergies, Sensitivities, Allergies(Required)

Sibling 4 Food Allergies

Sibling 5(Required)

First Last

Date of Birth(Required)

Sibling 4 Date of Birth

Current Age(Required)

Tshirt Size(Required)

Sibling 5 Tshirt Size

Food Allergies, Sensitivities, Allergies(Required)

Sibling 5 Food Allergies

Other Details

How did you hear about Anchor Point’s Pathway to Hope Camp?

What brought you to completing an application for Pathway to Hope?

What does your family hope to gain from coming to camp?

What are you family’s major strengths?

What are your family’s major challenges?

CHILD PROFILE (Complete for each child)

Name

First Last

Is this child adopted?

Yes

If so, type of adoption?

If International, which country?

Previous Care (if applicable)

Category 1

Type of Care (i.e., foster care, orphanage, group home, only our home, etc.)

Age of Stay

Duration of Stay

Category 2

Type of Care (i.e., foster care, orphanage, group home, only our home, etc.)

Age of Stay

Duration of Stay

Category 3

Type of Care (i.e., foster care, orphanage, group home, only our home, etc.)

Age of Stay

Duration of Stay

Has this child experienced:

A difficult pregnancy

Yes

If Yes, explain

A difficult birth

Yes

If Yes, explain

Early hospitalization

Yes

If Yes, explain

Neglect

Yes

If Yes, explain

Physical Abuse

Yes

If Yes, explain

Sexual Abuse

Yes

If Yes, explain

Loss of a Primary Caregiver

Yes

If Yes, explain

Other Trauma

Yes

If Yes, explain

Child Medical History:

Does the child have any medical or physical diagnoses?

Yes

If Yes, explain

Does the child have any known allergies or food restrictions?

Yes

If Yes, explain

Does this child have any limiting physical difficulties?

Yes

If Yes, explain

Has this child received any psychological diagnoses (e.g., ADD/ADHD, Autism, ODD, etc.)?

Yes

If Yes, explain

Has this child ever been hospitalized for a serious injury (e.g., broken bones, head trauma, bleeding)?

Yes

If Yes, explain

Has this child ever been hospitalized for a significant illness (e.g., pneumonia, asthma, etc)?

Yes

If Yes, explain

Has this child ever been hospitalized for behavioral or emotional problems?

Yes

If Yes, explain

Medical Diagnoses

Diagnosis 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Diagnosis 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Would you like to add another diagnoses?(Required)

Yes

Diagnosis 3

Label

Date of Diagnosis

Current Medications (if any)

Comments

Diagnosis 4

Label

Date of Diagnosis

Current Medications (if any)

Comments

Allergies or Food Restrictions

Restriction 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Restriction 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Would you like to add another restrictions?(Required)

Yes

Restriction 3

Label

Date of Diagnosis

Current Medications (if any)

Comments

Restriction 4

Label

Date of Diagnosis

Current Medications (if any)

Comments

Physical Limitations

Difficulty 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Difficulty 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Would you like to add another limitations?(Required)

Yes

Difficulty 3

Label

Date of Diagnosis

Current Medications (if any)

Comments

Difficulty 4

Label

Date of Diagnosis

Current Medications (if any)

Comments

Psychological Diagnosis

Diagnosis 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Diagnosis 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Would you like to add Phsychological Diagnosis?(Required)

Yes

Diagnosis 3

Label

Date of Diagnosis

Current Medications (if any)

Comments

Diagnosis 4

Label

Date of Diagnosis

Current Medications (if any)

Comments

Serious Injuries

Injury 1

Cause

Date of Injury

Duration of Stay

Comments

Injury 2

Cause

Date of Injury

Duration of Stay

Comments

Would you like to add Injury(Required)

Yes

Injury 3

Cause

Date of Injury

Duration of Stay

Comments

Injury 4

Cause

Date of Injury

Duration of Stay

Comments

Serious Illness

Illness 1

Illness

Date of Onset

Duration of Stay

Comments

Illness 2

Illness

Date of Onset

Duration of Stay

Comments

Would you like to add another illness?(Required)

Yes

Illness 3

Illness

Date of Onset

Duration of Stay

Comments

Illness 4

Illness

Date of Onset

Duration of Stay

Comments

Behavioral or Emotional Problems

Hospitalization 1

Reason

Date of Entry

Duration of Stay

Comments

Hospitalization 2

Reason

Date of Entry

Duration of Stay

Comments

Would you like to add another hospitalization?(Required)

Yes

Hospitalization 3

Reason

Date of Entry

Duration of Stay

Comments

Hospitalization 4

Reason

Date of Entry

Duration of Stay

Comments

Concerns:

Does the child have behavioral difficulties?

Yes

If Yes, explain

Does the child have emotional difficulties?

Yes

If Yes, explain

Does this child have educational difficulties?

Yes

If Yes, explain

Does this child have sensory difficulties?

Yes

If Yes, explain

Does this child have social difficulties?

Yes

If Yes, explain

Have you ever worried about the physical safety of your child or others around your child because of the emotional or behavioral difficulties your child may be experiencing?

Yes

If Yes, explain

Has your child ever harmed or attempted to harm another person, animal or himself?

Yes

If Yes, explain

What are these child’s major strengths?

What are these child’s major challenges?

Please list three goals you have for this child during camp

Are any other children residing in the home? YES NO(Required)

Yes

** if yes, please complete child profile for each child in family.

CHILD PROFILE

Name

First Last

Is this child adopted?

Yes

If so, type of adoption?

If International , which country?

Previous Care (if applicable)

Care Environment 1

Type of Care (i.e., foster care, orphanage, group home, only our home, etc.)

Age at Entry

Duration of Stay

Care Environment 2

Type of Care (i.e., foster care, orphanage, group home, only our home, etc.)

Age at Entry

Duration of Stay

Care Environment 3

Type of Care (i.e., foster care, orphanage, group home, only our home, etc.)

Age at Entry

Duration of Stay

Has this child experienced:

A difficult pregnancy

Yes

If yes, explain

A difficult birth

Yes

If yes, explain

Early hospitalization

Yes

If yes, explain

Neglect

Yes

If yes, explain

Physical Abuse

Yes

If yes, explain

Sexual Abuse

Yes

If yes, explain

Loss of a Primary Caregiver

Yes

If yes, explain

Other Trauma

Yes

If yes, explain

Child Medical History:

Does the child have any medical or physical diagnoses?

Yes

If yes, explain

Does the child have any known allergies or food restrictions?

Yes

If yes, explain

Does this child have any limiting physical difficulties?

Yes

If yes, explain

Has this child received any psychological diagnoses (e.g., ADD/ADHD, Autism, ODD, etc.)?

Yes

If yes, explain

Has this child ever been hospitalized for a serious injury (e.g., broken bones, head trauma, bleeding)?

Yes

If yes, explain

Has this child ever been hospitalized for a significant illness (e.g., pneumonia, asthma, etc)?

Yes

If yes, explain

Has this child ever been hospitalized for behavioral or emotional problems?

Yes

If yes, explain

Medical Diagnoses

Diagnosis 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Diagnosis 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Would you like to add another diagnosis?(Required)

Yes

Diagnosis 3

Label

Date of Diagnosis

Current Medications (if any)

Comments

Diagnosis 4

Label

Date of Diagnosis

Current Medications (if any)

Comments

Allergies or Food Restrictions

Restriction 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Restriction 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Would you like to add another restrictions?(Required)

Yes

Restriction 3

Label

Date of Diagnosis

Current Medications (if any)

Comments

Restriction 4

Label

Date of Diagnosis

Current Medications (if any)

Comments

Physical Limitations

Difficulty 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Difficulty 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Would you like to add another physical limitations?(Required)

Yes

Difficulty 3

Label

Date of Diagnosis

Current Medications (if any)

Comments

Difficulty 4

Label

Date of Diagnosis

Current Medications (if any)

Comments

Psychological Diagnosis

Diagnosis 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Diagnosis 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Would you like to add another psychological diagnosis?(Required)

Yes

Diagnosis 3

Label

Date of Diagnosis

Current Medications (if any)

Comments

Diagnosis 4

Label

Date of Diagnosis

Current Medications (if any)

Comments

Serious Injuries

Injury 1

Cause

Date of Injury

Duration of Stay

Comments

Injury 2

Cause

Date of Injury

Duration of Stay

Comments

Would you like to add another physical injury?(Required)

Yes

Injury 3

Cause

Date of Injury

Duration of Stay

Comments

Injury 4

Cause

Date of Injury

Duration of Stay

Comments

Serious Illness

Illness 1

Illness

Date of Onset

Duration of Stay

Comments

Illness 2

Illness

Date of Onset

Duration of Stay

Comments

Would you like to add another serious illness?(Required)

Yes

Illness 3

Illness

Date of Onset

Duration of Stay

Comments

Illness 4

Illness

Date of Onset

Duration of Stay

Comments

Behavioral or Emotional Problems

Hospitalization 1

Reason

Date of Entry

Duration of Stay

Comments

Hospitalization 2

Reason

Date of Entry

Duration of Stay

Comments

Would you like to add another hospitalization?(Required)

Yes

Hospitalization 3

Reason

Date of Entry

Duration of Stay

Comments

Hospitalization 4

Reason

Date of Entry

Duration of Stay

Comments

Concerns:

Does the child have behavioral difficulties?

Yes

If Yes, explain

Does the child have emotional difficulties?

Yes

If Yes, explain

Does this child have educational difficulties?

Yes

If Yes, explain

Does this child have sensory difficulties?

Yes

If Yes, explain

Does this child have social difficulties?

Yes

If Yes, explain

Have you ever worried about the physical safety of your child or others around your child because of the emotional or behavioral difficulties your child may be experiencing?

Yes

If Yes, explain

Has your child ever harmed or attempted to harm another person, animal or himself?

Yes

If Yes, explain

What are these child’s major strengths?

What are these child’s major challenges?

Please list three goals you have for this child during camp

Do you want to add another Child Profile(Required)

Yes

Child Profile

Name

First Last

Is this child adopted?

Yes

If so, type of adoption?

If International, which country?

Previous Care

Care Environment 1

Type of Care

Age of Entry

Duration of Stay

Care Environment 2

Type of Care

Age of Entry

Duration of Stay

Care Environment 3

Type of Care

Age of Entry

Duration of Stay

Care Environment 4

Type of Care

Age of Entry

Duration of Stay

Has this child experience:

A difficult pregnancy

Yes

If Yes, explain

A difficult birth

Yes

If Yes, explain

Early hospitalization

Yes

If Yes, explain

Neglect

Yes

If Yes, explain

Physical Abuse

Yes

If Yes, explain

Sexual Abuse

Yes

If Yes, explain

Loss of primary caregiver

Yes

If Yes, explain

Other Trauma

Yes

If Yes, explain

Child Medical History

Does the child have any medical or physical diagnoses?

Yes

If Yes, explain

Does the child have any known allergies or food restrictions?

Yes

If Yes, explain

Does this child have any limiting physical difficulties?

Yes

If Yes, explain

Has this child received any psychological diagnoses (e.g., ADD/ADHD, Autism, ODD, etc.)?

Yes

If Yes, explain

Does the child have any medical or physical diagnoses?

Yes

If Yes, explain

Has this child ever been hospitalized for a serious injury (e.g., broken bones, head trauma, bleeding)?

Yes

If Yes, explain

Has this child ever been hospitalized for a significant illness (e.g., pneumonia, asthma, etc)?

Yes

If Yes, explain

Has this child ever been hospitalized for behavioral or emotional problems?

Yes

If Yes, explain

Medical Diagnosis

Diagnosis 1

Label

Date of Diagnosis

Current Medication (If any)

Comments

Diagnosis 2

Label

Date of Diagnosis

Current Medication (If any)

Comments

Allergies or Food Restrictions

Restriction 1

Label

Date of Diagnosis

Current Medication (If any)

Comments

Restriction 2

Label

Date of Diagnosis

Current Medication (If any)

Comments

Restriction 3

Label

Date of Diagnosis

Current Medication (If any)

Comments

Physical Limitations

Diagnosis 1

Label

Date of Diagnosis

Current Medication (If any)

Comments

Diagnosis 2

Label

Date of Diagnosis

Current Medication (If any)

Comments

Diagnosis 3

Label

Date of Diagnosis

Current Medication (If any)

Comments

Serious Injuries

Injury 1

Cause

Date of Injury

Current Medication (If any)

Comments

Injury 2

Cause

Date of Injury

Current Medication (If any)

Comments

Injury 3

Cause

Date of Injury

Current Medication (If any)

Comments

Serious Illnesses

Illness 1

Illness

Date of Onset

Current Medication (If any)

Comments

Illness 2

Illness

Date of Onset

Current Medication (If any)

Comments

Behavioral or Emotional Problems

Hospitalization 1

Illness

Date of Onset

Current Medication (If any)

Comments

Hospitalization 2

Illness

Date of Onset

Current Medication (If any)

Comments

Hospitalization 3

Illness

Date of Onset

Current Medication (If any)

Comments

Concerns

Does the child have behavioral difficulties?

Yes

If Yes, explain

Does the child have emotional difficulties?

Yes

If Yes, explain

Does this child have educational difficulties?

Yes

If Yes, explain

Does this child have sensory difficulties?

Yes

If Yes, explain

Does this child have social difficulties?

Yes

If Yes, explain

Have you ever worried about the physical safety of your child or others around your child because of the emotional or behavioral difficulties your child may be experiencing?

Yes

If Yes, explain

Has your child ever harmed or attempted to harm another person, animal or himself?

Yes

If Yes, explain

What are these child’s major strengths?

What are these child’s major challenges?

Please list three goals you have for this child during camp

Add another child profile?(Required)

Yes

Child Profile

Name

First Last

Is this child adopted?

Yes

If so, type of adoption

If international, which country?

Previous Care (if applicable)

Care Environment 1

Type of Care (i.e., foster care, orphanage, group home, only our home, etc.)

Age at Entry

Duration of Stay

Care Environment 2

Type of Care (i.e., foster care, orphanage, group home, only our home, etc.)

Age at Entry

Duration of Stay

Care Environment 3

Type of Care (i.e., foster care, orphanage, group home, only our home, etc.)

Age at Entry

Duration of Stay

Has this child experienced:

A difficult pregnancy

Yes

If yes, explain

A difficult birth

Yes

If yes, explain

Early hospitalization

Yes

If yes, explain

Neglect

Yes

If yes, explain

Physical Abuse

Yes

If yes, explain

Sexual Abuse

Yes

If yes, explain

Loss of a Primary Caregiver

Yes

If yes, explain

Other Trauma

Yes

If yes, explain

Child Medical History:

Does the child have any medical or physical diagnoses?

Yes

If yes, explain

Does the child have any known allergies or food restrictions?

Yes

If yes, explain

Does this child have any limiting physical difficulties?

Yes

If yes, explain

Has this child received any psychological diagnoses (e.g., ADD/ADHD, Autism, ODD, etc.)?

Yes

If yes, explain

Has this child ever been hospitalized for a serious injury (e.g., broken bones, head trauma, bleeding)?

Yes

If yes, explain

Has this child ever been hospitalized for a significant illness (e.g., pneumonia, asthma, etc)?

Yes

If yes, explain

Has this child ever been hospitalized for behavioral or emotional problems?

Yes

If yes, explain

Medical Diagnoses

Diagnosis 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Diagnosis 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Allergies or Food Restrictions

Restriction 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Restriction 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Physical Limitations

Difficulty 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Difficulty 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Serious Injuries

Diagnosis 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Diagnosis 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Serious Injuries

Injury 1

Cause

Date of Injury

Date of Stay

Comments

Injury 2

Cause

Date of Injury

Date of Stay

Comments

Serious Illness

Illness 2

Inllness

Date of Onset

Date of Stay

Comments

Illness 1

Illness

Date of Onset

Date of Stay

Comments

Behavioral or Emotional Problems

Hospitalization 1

Reason

Date of Entry

Date of Stay

Comments

Hospitalization 2

Reason

Date of Entry

Date of Stay

Comments

Concerns:

Does the child have behavioral difficulties?

Yes

If yes, epxlain

Does the child have emotional difficulties?

Yes

If yes, epxlain

Does this child have educational difficulties?

Yes

If yes, epxlain

Does this child have sensory difficulties?

Yes

If yes, epxlain

Does this child have social difficulties?

Yes

If yes, epxlain

Have you ever worried about the physical safety of your child or others around your child because of the emotional or behavioral difficulties your child may be experiencing?

Yes

If yes, epxlain

Has your child ever harmed or attempted to harm another person, animal or himself?

Yes

If yes, epxlain

What are these child’s major strengths?

What are these child’s major challenges?

Please list three goals you have for this child during camp

Do you like to add another child profile?(Required)

Yes

Child Profile

Name

First Last

Is this child adopted?

Yes

If so, type of adoption?

If international, which country?

Previous care (If applicable)

Care Environment 1

Type of Care (i.e., foster care, orphanage, group home, only our home, etc.)

Age of Entry

Duration of Stay

Care Environment 2

Type of Care (i.e., foster care, orphanage, group home, only our home, etc.)

Age of Entry

Duration of Stay

Care Environment 3

Type of Care (i.e., foster care, orphanage, group home, only our home, etc.)

Age of Entry

Duration of Stay

Has this child experienced:

A difficult pregnancy

Yes

If yes, explain

A difficult birth

Yes

If yes, explain

Early hospitalization

Yes

If yes, explain

Neglect

Yes

If yes, explain

Physical Abuse

Yes

If yes, explain

Sexual Abuse

Yes

If yes, explain

Loss of a Primary Caregiver

Yes

If yes, explain

Other Trauma

Yes

If yes, explain

Child Medical History

Does the child have any medical or physical diagnoses?

Yes

If yes, explain

Does the child have any known allergies or food restrictions?

Yes

If yes, explain

Does this child have any limiting physical difficulties?

Yes

If yes, explain

Has this child received any psychological diagnoses (e.g., ADD/ADHD, Autism, ODD, etc.)?

Yes

If yes, explain

Has this child ever been hospitalized for a serious injury (e.g., broken bones, head trauma, bleeding)?

Yes

If yes, explain

Has this child ever been hospitalized for a significant illness (e.g., pneumonia, asthma, etc)?

Yes

If yes, explain

Has this child ever been hospitalized for behavioral or emotional problem?

Yes

If yes, explain

Medical Diagnoses

Diagnosis 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Diagnosis 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Allergies or Food Restrictions

Restriction 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Restriction 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Physical Limitations

Difficulty 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Difficulty 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Psychological Diagnosis

Diagnosis 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Diagnosis 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Serious Injuries

Injury 1

Cause

Date of Injury

Current Medications (if any)

Comments

Injury 2

Cause

Date of Injury

Current Medications (if any)

Comments

Serious Illness

Illness 1

Illness

Date of Onset

Current Medications (if any)

Comments

Illness 2

Illness

Date of Onset

Current Medications (if any)

Comments

Behavioral or Emotional Problems

Hospitalization 1

Reason

Date of Entry

Current Medications (if any)

Comments

Hospitalization 2

Reason

Date of Entry

Current Medications (if any)

Comments

Concerns:

Does the child have behavioral difficulties?

Yes

If yes, explain

Does the child have emotional difficulties?

Yes

If yes, explain

Does this child have sensory difficulties?

Yes

If yes, explain

Does this child have social difficulties?

Yes

If yes, explain

Have you ever worried about the physical safety of your child or others around your child because of the emotional or behavioral difficulties your child may be experiencing?

Yes

If yes, explain

Has your child ever harmed or attempted to harm another person, animal or himself?

Yes

If yes, explain

What are these child’s major strengths?

What are these child’s major challenges?

Please list three goals you have for this child during camp

Do you want to add another child profile?(Required)

Yes

Child Profile

Name

First Last

Is this child adopted?

Yes

If so, type of adoption

If international, which country?

Previous Care (if applicable)

Care Environment 1

Type of Care (i.e., foster care, orphanage, group home, only our home, etc.)

Age of Entry

Duration of Stay

Care Environment 2

Type of Care (i.e., foster care, orphanage, group home, only our home, etc.)

Age of Entry

Duration of Stay

Care Environment 3

Type of Care (i.e., foster care, orphanage, group home, only our home, etc.)

Age of Entry

Duration of Stay

Child Medical History:

Does the child have any medical or physical diagnoses?

First Choice

Second Choice

Third Choice

If yes, explain

Does the child have any known allergies or food restrictions?

First Choice

Second Choice

Third Choice

If yes, explain

Does this child have any limiting physical difficulties?

First Choice

Second Choice

Third Choice

If yes, explain

Has this child received any psychological diagnoses (e.g., ADD/ADHD, Autism, ODD, etc.)?

First Choice

Second Choice

Third Choice

If yes, explain

Has this child ever been hospitalized for a serious injury (e.g., broken bones, head trauma, bleeding)?

First Choice

Second Choice

Third Choice

If yes, explain

Has this child ever been hospitalized for a significant illness (e.g., pneumonia, asthma, etc)?

First Choice

Second Choice

Third Choice

If yes, explain

Has this child ever been hospitalized for behavioral or emotional problem?

First Choice

Second Choice

Third Choice

If yes, explain

Medical Diagnoses

Diagnosis 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Diagnosis 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Allergies or Food Restrictions

Restriction 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Restriction 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Physical Limitations

Difficulty 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Difficulty 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Psychological Diagnosis

Diagnosis 1

Label

Date of Diagnosis

Current Medications (if any)

Comments

Diagnosis 2

Label

Date of Diagnosis

Current Medications (if any)

Comments

Diagnosis 3

Label

Date of Diagnosis

Current Medications (if any)

Comments

Serious Injuries

Injury 1

Cause

Date of Injury

Duration of Stay

Comments

Injury 2

Cause

Date of Injury

Duration of Stay

Comments

Serious Illness

Illness 1

illness

Date of Onset

Duration of Stay

Comments

Illness 2

illness

Date of Onset

Duration of Stay

Comments

Behavioral or Emotional Problems

Hospitalization 1

Reason

Date of Entry

Duration of Stay

Comments

Hospitalization 2

Reason

Date of Entry

Duration of Stay

Comments

Concerns

Does the child have behavioral difficulties?

Yes

If yes, explain

Does the child have emotional difficulties?

Yes

If yes, explain

Does this child have educational difficulties?

Yes

If yes, explain

Does this child have sensory difficulties?

Yes

If yes, explain

Does this child have social difficulties?

Yes

If yes, explain

Have you ever worried about the physical safety of your child or others around your child because of the emotional or behavioral difficulties your child may be experiencing?

Yes

If yes, explain

Has your child ever harmed or attempted to harm another person, animal or himself?

Yes

If yes, explain

What are these child’s major strengths?

What are these child’s major challenges?

Please list three goals you have for this child during camp

Dear Prospective Camp Family,

SUMMER 2025

Family Camp Application

Parent's Information

Child Information

Sibling Information

Other Details

CHILD PROFILE (Complete for each child)

Previous Care (if applicable)

Has this child experienced:

Child Medical History:

Medical Diagnoses

Allergies or Food Restrictions

Physical Limitations

Psychological Diagnosis

Serious Injuries

Serious Illness

Behavioral or Emotional Problems

Concerns:

CHILD PROFILE

Previous Care (if applicable)

Has this child experienced:

Child Medical History:

Medical Diagnoses

Allergies or Food Restrictions

Physical Limitations

Psychological Diagnosis

Serious Injuries

Serious Illness

Behavioral or Emotional Problems

Concerns:

Child Profile

Previous Care

Has this child experience:

Child Medical History

Medical Diagnosis

Allergies or Food Restrictions

Physical Limitations

Serious Injuries

Serious Illnesses

Behavioral or Emotional Problems

Concerns

Child Profile

Previous Care (if applicable)

Has this child experienced:

Child Medical History:

Medical Diagnoses

Allergies or Food Restrictions

Physical Limitations

Serious Injuries

Serious Injuries

Serious Illness

Behavioral or Emotional Problems

Concerns:

Child Profile

Previous care (If applicable)

Has this child experienced:

Child Medical History

Medical Diagnoses

Allergies or Food Restrictions

Physical Limitations

Psychological Diagnosis

Serious Injuries

Serious Illness

Behavioral or Emotional Problems

Concerns:

Child Profile

Previous Care (if applicable)

Child Medical History:

Medical Diagnoses

Allergies or Food Restrictions

Physical Limitations

Psychological Diagnosis

Serious Injuries

Serious Illness

Behavioral or Emotional Problems

Concerns

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