Camp Little Tree: For Children with Sensory Integration Issues
Little Tree is a camp for sensory integration impairments, as well as learning and/or attention deficits. The 5 day
program is designed to meet the unique needs of these children. Occupational Therapy (OT) and SI principles are
used to provide sensory-motor, social and emotional support. Adapting the activities fosters success and a sense of
achievement in a mountain setting.
Focus is placed on developing independence, competence, social skills and self esteem. Children live, work and play
in a “family” group of 6-8 campers, 2-3 outdoor educators from Breckenridge Outdoor Education Center, and 2
specialized OT’s from The Children’s Hospital. Campers assist in cooking and cabin clean-up along with peers and
adults. Children participate daily in climbing, canoeing, ropes courses and outdoor education. Other activities include
field games, crafts, journal writing, and fishing. Involvement in these programs encourages motor skills, coordination,
motor planning and self confidence.
Eligible Participants
The Camp Little Tree summer program is intended for children 8-12 years of age with sensory integration issues. In
addition, the following criteria for participation have been established:

Must be fully independent with all toileting skills

Must be willing and able to use an outhouse

Must be able to follow instructions and comply with adult requests

Must be able to remain with a group of 13 people without constant one on one attention

May not have extreme emotional and/or psychological distress

Must have therapist’s recommendation for involvement in Camp Little Tree
Session Information
This year camp will be held in the Old Cabin at the Breckenridge Outdoor Education Center.
2012 Camp Little Tree:
June 15th-19th
Equipment
Upon acceptance to camp a complete list materials needed for camp will be sent out. Some of the items will include a
sleeping bag, water bottle, clothing, boots, and a hat.
Transportation
Please note that families are responsible for transportation to and from camp.
Camp Little Tree takes place at: Breckenridge Outdoor Education Center (BOEC) in Breckenridge, Colorado.
(1 hour 45 minutes west of Denver)
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045
Funding
Scholarship assistance may be available, so please don’t let camp costs deter your child from participating. Payment
for camp must be made no later than May 31st.
Cost of Camp (per child)
$1090 Starting Cost of Camp
-
$465 Charitable donations received by each camper
______
$625 Cost to Families (**see statement below for additional funding available)
**Additional funding may be available via qualification and completion of the Financial Assistance Application
included in this camp application. The Camp Little Tree program is financed solely by philanthropic donations. Every
attempt is made to make financial assistance available for individuals with identified needs. Resources for camper
scholarships are subject to the amount of funds raised each year for this purpose. Camp fees are not billed to
insurance providers.
Application Process: Due by Monday April 30th, 2012
To apply for Camp Little Tree, please complete the enclosed forms (list below) and return them to:
The Children’s Hospital
Attn: Felicia Latsko, B285
13123 East 16th Avenue
Aurora, CO 80045
Or fax to 720-777-7297 (attn: Felicia)
All applicants will be screened for appropriateness and must meet all of the requirements for involvement. Priority
will be given to applications that are 100% completed and on a first come basis.
 The Camp application
 The Physician Permission form must be completed by your child’s primary care physician
 The Therapist Recommendations (this can be sent separately by therapist)
 The Children’s Hospital Liability Release
 BOEC Acknowledgement of Risk and Release of Liability
 The Children’s Hospital Media Release
 Authorization to Use and Disclose Protected Health Information
 The Financial Assistance Application will be used to determine requests for need-based financial assistance for
Camp Little Tree
Please also include copies of current Occupational Therapy reports and any other information that will help us better
understand the needs of your child.
For Information on Camp Little Tree
For more information and a camp application, please call: (720) 777-3456. Our fax number is (720) 777-7297
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045
Camp Application
Please fill out this application completely.
Demographic Information:
Name (please print)
_______________________________________________________________________________
Address/Street___________________________________________________________________________________
City_________________________________ State__________ Zip ____________ Phone______________________
Age ______
Birth date _____________
Sex ______
Height _______ Weight _______
Parent/guardian________________________________Email__________________________________________
Home phone_____________________________
Work phone ___________________________________
Name of person(s) to be notified in an emergency:
Name
____________________________________________________ Relationship________________________
Phone (h) ___________________________________
Name
(w) _____________________________________________
____________________________________________________ Relationship________________________
Phone (h) ___________________________________
(w) _____________________________________________
Describe your child’s sensory integration issues:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Medical History:
1. Is your child covered by a hospitalization and medical care policy? □ Yes □ No
2. If yes, name the insurance company : ___________________________________Policy # ___________________
3. Name of child’s doctor ______________________________________ Phone # ___________________________
4. Within the last year, has your child had any illnesses, injuries of surgeries ________________________________
5. List any medical diagnoses _____________________________________________________________________
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045
6. Does your child have any allergies? ______________________________________________________________
7.
8.
9.
10.
List any dietary restrictions or precautions: ________________________________________________________
Date of last physical examination: _______________________________________________________________
Date of last tetanus immunization: _______________________________________________________________
If your child has had any of the following conditions, please circle and give details at the end of the section:
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Any problem with vision or hearing - requires glasses, hearing aid, etc.
Problems with teeth – use of braces, etc.
Dizzy spells, fainting, convulsions,
persistent headaches, etc.
Frequent infections of throat, tonsils,
sinuses, ears.
Chronic cough, bronchitis, bloody sputum.
Asthma or respiratory problems.
Palpitation of the heart, irregular
heartbeat, heart murmurs, etc.
Jaundice or hepatitis.
Frequent abdominal cramping or severe
menstrual cramps.
Difficulty urinating, pain on urination, bed
wetting.
Frequent diarrhea or blood in stools.
Kidney infection or stones.
Spasticity, rigidity, poor muscle tone or
limited range of motion
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Catheter/leg bag
Broken bones, joint dislocations, serious
sprains.
Any severe injury to chest or internal organs.
Chronic skin problems, rashes, infections, etc.
Reaction to extremes of temperature, previous
frostbite, poor circulation, etc.
Allergy to medicines, foods, insect bites, bees,
etc.
Diabetes, thyroid trouble, bleeding problems.
Incontinence.
Sleep walking.
ADD (Attention Deficit Disorder), ADHD
(Attention Deficit Hyperactivity Disorder).
Other significant medical or neurologic
disorders.
Seizures/Epilepsy:
Date of last seizure __________________________Type of seizure _________________________________
Current status (active or controlled) ___________________Duration __________How often _____________
Describe reaction before, during and after seizure________________________________________________
______________________________________________________________________________________
Details of other conditions_________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Medications:
Name of Medication
Dosage
Times Given
Total Doses per day
Reason for medication
How does he/she take the medication (chew, swallow with liquid, swallow with food, etc.)?
__________________________________________________________________________________________
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045
__________________________________________________________________________________________
Do we have permission to give your child Aspirin or Tylenol in the case of a headache or minor pain?
□ Yes □ No □ Call first
Self help skills:
1. Can your child dress himself/herself completely without help? □ Yes □ No (If no, what does your child need
help with?
___________________________________________________________________________________
2. Does your child need any help with hygiene? □ Yes □ No (If yes, what?)______________________________
3. Is your child fully potty trained? □ Yes □ No Does your child have any bowel or bladder trouble? □ Yes □ No
Does your child wet the bed? □Yes □No
Would your child be willing to use an outhouse? □Yes □No
Therapy:
1. Is your child currently receiving therapy? □ Yes □ No If yes, what is the frequency of the treatment?
Occupational Therapy _______ per month Therapist
Phone # ___________________
Physical Therapy
_ per month Therapist
Phone # ___________________
Speech Therapy
_ per month Therapist
Phone # ___________________
Other
_ per month Therapist
Phone # ___________________
2. Has your child had any of the above therapies in the past? □ Yes □ No If so, please describe: (please include
any current or previous therapy reports that will help us know more about your child)
______________
Educational History:
My child:
Is not yet in school
_____yes
_____no
Is having difficulty with schoolwork
_____yes
_____no
(If yes, please describe) ___________________________________________________________
_______________________________________________________________________________
Receives special services: (list) ___________________________________________________________
______________________________________________________________________________________
School: _______________________________ Grade: _________ Teacher: _______________________
Experience:
1. Please circle the appropriate response.
Overnight Camping
None
Some
Extensive
Rock Climbing
None
Some
Extensive
Canoeing
None
Some
Extensive
Rafting
None
Some
Extensive
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045
Swimming
None
Some
Extensive
Ropes Course
None
Some
Extensive
2. Other related skills or interests:
a) What does your child do well? ______________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
b) What is difficult for your child to do? _________________________________________________
__________________________________________________________________________________
c) What activities does your child like to do? _____________________________________________
__________________________________________________________________________________
d) What activities does your child not like to do (or not do very often)? ________________________
__________________________________________________________________________________
3. Areas of Restriction: (please describe restriction)
Swimming __________________________
Athletics ___________________________
Overnight Camping ___________________
Supervised ropes course ________________
Hiking _____________________________
Boating _____________________________
4. Has your child attended any overnight camp before?
Has your child attended a BOEC course before?
______yes
______no
______yes
______no
Why are you interested in having your child participate in this camp? ___________________________
___________________________________________________________________________________
What would you like him/her to gain from camp? ___________________________________________
___________________________________________________________________________________
Please share any other information about your concerns or your child’s needs that would help our staff plan a more
enriching experience for your child. __________________________________-______________
____________________________________________________________________________________
Please indicate any dates your child would be unavailable for camp: ___________________________
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045
Sensory Questionnaire
Adapted from the Short Sensory Profile by
Winni Dunn, Ph.D.,OTR, FAOTA
Scoring Criteria: No = 0 - 25% of the time, Sometimes = 25% - 75% of the time, Yes = 75% - 100% of time.
Item
No
Sometimes
Yes
Expresses distress with grooming
(cries or resists hair brushing, washing)
Reacts emotionally or aggressively to touch
Withdraws from splashing water
Has difficulty standing near others
Avoids being barefoot on grass or sand
Will only eat certain foods
Becomes anxious when feet are off the ground
Fear or falling or heights
Seeks out movement (fidgets a lot)
Doesn’t notice when face or hands get messy
Is distresses with hands or face is messy
Becomes overly excited during movement activities
Limited attention
Has trouble attending with background noise
Is fearful of certain sounds
Tires easily or seems weak
Has a weak grasp on a pencil
Is bothered by bright lights
Falls frequently or seems clumsy
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045
Acknowledgement of Risk and Release of Liability (The Children’s Hospital)
I hereby affirm that I am the parent of legal guardian of __________________________________________
(participant)
Who has my permission to participate in a program of skiing provided by The Children's Hospital
Association (Hospital) and the Breckenridge Outdoor Education Center (BOEC.)
I recognize that the Child’s participation in the skiing program and related activities involves risk of bodily
injury and property damage and agree that the risk of any injury, loss or damage is assumed by the
Participant and the Participant’s parents or legal guardians.
I authorize BOEC and the Hospital to provide emergency medical treatment in the event the participant so
requires and release the Hospital, BOEC and their respective officers, agents, employees and representatives
from liability for all their decisions and actions, made and done in the good faith, in administering such
emergency medical treatment.
In the event I cannot be reached in an emergency, I hereby give permission to a physician selected by the
Hospital and/or BOEC to hospitalize, secure proper treatment for and to order injection, anesthesia, or
surgery for the above named Participant.
I release the owners and operators of BOEC, the Hospital, and their respective officers, agents, employees
and representatives from legal responsibility for personal injury to the Participant, or loss or damage to the
Participant’s property resulting from participation I the skiing program and activities coincidental to it such
as use of specialized sporting equipment, travel to and from the ski area, meals, rest and waiting periods.
Date
Signature of Parent or Guardian
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045
Letter to Students, Parents, and Guardians from BOEC
We, the staff of the Breckenridge Outdoor Education Center (BOEC), look forward to having you, your child or your family
member join us for a program experience on the ski slopes, at our Breckenridge campus and/or in one of our “wilderness” venues.
On these two pages, you will find important information about the BOEC, our activities and the potential risks involved in
participation. Please read this information carefully, ask us any questions you might have and do not sign this agreement if you
do not want to be exposed to these activities!
The BOEC is a non-profit organization that has been in operation since 1976, providing outdoor adventure programs for people of
all ages and abilities. We offer activities and programs for groups and individuals throughout the year. All activities are
structured to address the specific goals and abilities of our students.
We conduct all our activities consistent with the standards set out by the Association for Experiential Education (AEE) and the
Professional Ski Instructors Association (PSIA). You can be confident in knowing that the BOEC is accredited by AEE, who
independently reviews the policies, practices and educational components of applicant organizations. The AEE only accredits
those programs that meet its high standards. All activities offered are designed to pose an appropriate level of challenge for our
students.
Please know that participation in BOEC activities involve risk. These risks will be greater than most people encounter in their
daily lives, which is what BOEC is all about. Providing high quality programs in a risk-managed environment is a priority at the
BOEC. We cannot eliminate all risks in adventure activities such as snow skiing or boarding, rafting, rock climbing or most of
the activities that we do. These activities can cause injury and even serious injury. As with any outdoor adventure, under rare
circumstances, the activity can even result in death.
It is of utmost importance to us that you do not engage in activities that could be detrimental to your health or which is opposed
by you, your family, or your doctor due to illness, injury, physical or mental infirmity, or any other health/medical condition that
you may have, whether diagnosed or undiagnosed.
To help us manage these risks it is very important that you follow all directions given by the BOEC staff and you ask questions
whenever a procedure or activity is unclear to you. If you are currently taking prescription medications, including medical
marijuana or other alternative therapies, it is imperative that these medications be disclosed in your confidential medical form.
Use of, or being under the influence alcohol or judgment affecting drugs while participating in adventure activities, is strictly
prohibited.
We believe that it is in everyone’s best interest that risks are disclosed, understood, and assumed prior to participation at the
BOEC. After you have reviewed both sides of this Acknowledgement of Risk and Release of Liability Form and if you
understand and agree with its contents, please sign and initial in the designated places on both pages. If you are the parent or
legal guardian of a student, again please read both sides of this form and if you both agree and understand their content, place
YOUR signature and initials in the designated places on both pages.
If you have any questions or comments about the level of risk at the BOEC, please do not hesitate to contact us. We welcome
your questions, suggestions and feedback.
Sincerely,
The BOEC Staff
I have read the above information
Student or Parent/Guardian
__________(initial)
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045
Acknowledgement of Risk and Release of Liability (BOEC)
In consideration of being allowed to participate in Breckenridge Outdoor Education Center (BOEC) programs, and related events
and activities, or serve as staff or volunteer for the same, I, and/or the minor student, and/or the person for which I am legal
guardian, the undersigned hereby understand and agree to the following:
1.
I understand that although the BOEC has taken precautions to provide proper organization, supervision, instruction and
equipment for each course, it is impossible for the BOEC to guarantee absolute safety. Also, I understand that I share the
responsibility for safety during all activities, and I accept that responsibility. I will make my instructors aware of any
questions or concerns I might have regarding my understanding of safety standards, guidelines, procedures and my
ability to participate at any point during any activity.
2.
I understand that risks during outdoor programs include, but are not limited to, loss or damage to personal property,
injury, permanent disability, mental anguish, exposure to inclement weather, slipping, falling, insect or animal bites,
vehicle accidents, being struck by falling objects, collisions with other parties, immersion in cold water, hypothermia
(cold exposure), hyperthermia (heat exposure), lightning, altitude related illnesses, severe social or economic losses that
may result from any such incident and even death. I also understand that such accidents or illnesses may occur in remote
areas without easy access to medical facilities or while traveling to and from the activity sites. Further, there may be
other risks not known to me or not reasonably foreseeable at this time.
3.
I agree that prior to participation, I will inspect, to the best of my ability, the facilities and equipment to be used. If I
believe anything is unsafe, I will immediately advise the BOEC staff of such condition and refuse to participate.
4.
I assume all the foregoing risks and accept personal responsibility for the damages due to such injury, permanent
disability or death resulting from participating in any BOEC activity.
5.
I agree that any claim of loss, legal action or lawsuit naming BOEC or its representatives that may occur as a result of
participation in a BOEC program will be tried in Summit County Colorado and apply Colorado law.
I hereby release the BOEC, its successors, representatives, assigns, Board of Directors, volunteers, employees, officers and other
participants from any and all claims, demands, and causes of action, whether resulting from negligence or otherwise, of every
nature and in conjunction with a BOEC activity.
________________________________
____________________________
PARTICIPANT’S PRINTED NAME
SIGNATURE
______________
DATE
If the participant is a minor and/or has a legal guardian:
________________________________
PARENT/GUARDIAN’S PRINTED NAME
____________________________
SIGNATURE
______________
DATE
In addition, the BOEC requests your permission on two other matters:
6. GRANT PERMISSION TO OBTAIN MEDICAL TREATMENT ON MY BEHALF
______Decline (initial)
Should I, or the person for whom I am the legal guardian, become injured or ill, I give permission for the BOEC Program Staff to
render first-aid and to seek emergency medical or rescue services as they see fit, and at my cost. (Please note: We recommend
that all BOEC students be covered by personal health insurance. If medical care for injury, pre-existing condition or any other
reason is required during a BOEC course, the student’s personal health insurance will be primary.)
7. GRANT PERMISSION TO TAKE AND DISPLAY IMAGES
______Decline (initial)
I hereby give my permission to the Breckenridge Outdoor Education Center (BOEC), and any person designated by the BOEC, to
make photographs and other recordings of myself, and I consent to publishing and/or displaying of such recordings as the BOEC
deems fit for the sole purpose of promotion of the BOEC.
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045
Media Release
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045
Patient Name __________________________________________________________ MR#_________________
Last First MI (completed by TCH)
Birth date _________________________ Phone____________________ SS# _________________________
Parent/Guardian/Requester Completing Form: ___________________________________________________
I authorize The Children's Hospital to Release Medical Record
Information to:
Name __Breckenridge Outdoor Education Center__
Address ______________________________________________
City/State/Zip ____Breckenridge, CO____________________
Phone __________________________ Fax ___________________
For the following purpose:
Purpose:
Release To
Patient
Information
Authorization for Disclosure of Protected Health
Information 680330 (Rev 9/07)
Fees:
□Pertinent Information (Discharge Summary, H&P, X-Ray, Lab, Surgery, EKG, etc)
□Emergency Room/Urgent Care □ Immunization Record
 Clinic Information/Notes □ Lab Reports
□ Discharge Summary □Imaging Results □Copy of Images
□Complete Medical Record (except ________________________)
□Other________________________________________________
The following fees are applicable and
authorized by Colorado State Law:
$ 14.00 - 1 - 10 pages
$ .50/pg - 11- 40 pages
$ .33/pg - each add’l page
$1.50 per page for microfilm
X-Ray film - $14.00 per sheet
X-Ray CD - $14.00 per CD
Confirmation
Information to Release
Treatment Dates: From__________________________________
To__________________________________
□Continuation of Care □Insurance
□Legal □Personal Use
□Other __________________________
Confirmation of Pick Up:
_________________________
Signature
Date ___________
___CD __ Film ___ Checked out Existing
Film
State/Federal Laws require specific authorization to release the
following types of information. Please initial beside the types of
information to be released:
Delivery
Instructions:
____ HIV/AIDS Related ____ Genetic Testing ___ Drug/Alcohol abuse
____ Mental Health ____ Psychotherapy Notes ___ Sickle Cell Anemia
□Call Requester for pick-up when records are ready.
□Mail records directly to person or organization specified.
□Other _______________________________________________
I authorize ___________________to pick up my Medical Records.
_______________________________________________
Patient/Authorized
Representative Authorization
Relationship to patient
I understand that: (1) My signature on this form is strictly voluntary. (2) I may revoke this authorization at any time in writing, and if I
do it will not have any effect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy
Practices. (3) If the requester or receiver is not a health plan or health care provider, the released information may be disclosed by the
recipient and may no longer be protected by federal privacy regulations. (4) If I do not sign this form, my health care, the payment for my
health care or my ability to enroll for benefits will not be affected. (5) I may inspect or obtain a copy of the health information that I am
being asked to disclose.
Expiration: Without my express revocation, this consent will automatically expire upon satisfaction of the need for disclosure, but in any
event will expire 180 days from the date hereof, unless otherwise specified: ______________.
□If this “box "is checked, the Facility will receive compensation for the use or disclosure of my information.
____________________________________ ___________________________ __________
Signature Relationship to patient Date
Health Information Mgmt / TCH / 13123 E. 16th Avenue Box 150 / Aurora, CO 80045 720-777-4259 / Fax 720-777-7251
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16th Avenue, B285 | Aurora, CO 80045
Financial Assistance Application
Child’s Name: ________________________________________ Birth date: _____________
Father’s Name: _______________________ Mother’s Name: ________________________
Marital Status: Married
Single
Divorced
Separated
(circle one)
Telephone: __________________________ How long at present address? ____________
Number of children in family: ________ Ages: _________________________
Financial Information
Father’s Employer: _____________________________________ How long? ______ Telephone:_______________
Father gets paid:
Weekly
Every 2 weeks
Monthly
(circle one)
Amount of take home pay each pay period _____________________
Mother’s Employer: _____________________________________ How long? ______ Telephone: ______________
Mother gets paid:
Weekly
Every 2 weeks
Monthly
(circle one)
Amount of take home pay each pay period ____________________
Other sources of income and approximate dollar amount received from each source:
_____________________________________________________________________
Checking Account Balance (approximate): ______________________________________
Savings Account Balance (approximate): _______________________________________
Automobiles:
Model/Year ____________________ Model/Year __________________
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045
Expenses
Original Balance
Current Balance
Monthly Payment
1. House Payment or Rent
2. Utilities (gas, elec., water, phone)
3. Groceries
4.
5.
6.
Has your child received Camp Financial Assistance previously? ___________________________
List any other resources you have, or are in the process of contacting, for financial assistance for camp (such as local
service organizations, like Kiwanis, or town or county community boards or groups):
______________________________________________________________________________________________
Estimation of amount family can pay: $ ________________________
Your application cannot be reviewed without the following:
1.
Current paycheck stub or letter of explanation regarding source of income (if paycheck stub is not
available).
2.
Estimation of amount family can pay toward child’s participation.
I hereby certify the above to be true to the best of my knowledge.
SIGNATURE: _________________________________________________________________
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045
Physician Permission Form
To be filled out by the child’s primary care physician
Date:
Name
Birth date
Address
City
Home Phone
Zip
Work Phone
Parents/Guardians
Diagnosis/Reason for Referral
Comments (include precautions)
I give my permission for the above named patient to participate in camping with The Children’s Hospital Camp Little
Tree program with Breckenridge Outdoor Education Center.
Physician’s Signature:
Print Physician’s Name:
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045
Therapist Recommendation Form
Date:___________
Name of Child: ________________________________________Child DOB: ______________
Therapist Completing this Form: ___________________________________________
Phone: ________________________
Do you recommend this child for Little Tree Summer Camp? _____________________
What are the child’s current therapy needs and goals?
What would you like to see this child accomplish at camp?
What approaches or techniques help this child succeed?
Please keep in mind primary criteria for camp acceptance. The child must be 8 years old, fully independent with
toileting and willing to use an outhouse, able to follow instructions given by an adult and comply with adult requests
and be able to remain with a group of 8 kids without constant 1:1 attention.
Please include any current evaluations with this form. You can return this to the family or send it directly to:
The Children’s Hospital
Attn: Felicia Latsko, B285
13123 East 16th Avenue
Aurora, CO 80045
Or fax to 720-777-7297 (attn: Felicia)
Camp Little Tree (720) 777-3456
The Children’s Hospital | Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045