The Children’s Institute
of Pittsburgh
Memo
From: Amy Haid, director of Community Resources and Training
Date: 2/9/2016
Re:
Camp Success Application Process
Thank you for your interest in Camp Success at The Children’s Institute of Pittsburgh!
To apply for Camp Success, please follow these steps:
1. Print and fill out a Camp Success Application for each child.
2. Return it via fax, email or regular mail to Amy Haid, director of Community Resources and
Training by April 25, 2015.
3. From April 28th –May 16th, the Camp Success coordinator will review all applications and
call to speak with the person submitting the application. At that time, the coordinator will
determine whether or not a particular child will or will not be accepted for placement
within Camp Success and inform the parent/caregiver of that decision.
Camp Success is an accessible, inclusive, non-therapeutic, single-site summer day camp for children
with and without disabilities. The camp accommodates children ages 6-12 with physical, sensory,
emotional, behavioral and cognitive needs*. Often times, families struggle to find summer programs
for their children because of barriers created by expense, transportation, exclusion of non-disabled
siblings, and inability to accommodate children with behavioral problems.
Camp Success is a family enrichment program offered by The Children’s Institute of Pittsburgh. It
serves Pittsburgh’s East End and surrounding communities.
*There are varying degrees of ability in these areas. During the application review process, the camp
coordinator will determine if Camp Success is able to safely meet the special needs of each child applying for
admittance.
Application for Camp Success 2015
Please complete application & return to Amy Haid by April 25, 2015
1405 Shady Avenue, Pittsburgh, PA 15217 * Fax 412.420.2143 * aeh@the-institute.org
Participant Information
Name: _____________________________ Nick-Name:____________________________
Date of Birth: __________________ Age: _______
Address: ________________________________ Home Phone:______________________
_________________________________________ Cell Phone: ________________________
Parent/Guardian Name:_______________________________________________________
Has your child attended Camp Success before? Yes/No
If Yes, when? ___________________________________________
Medical Information
Primary Care Physician: ________________________ Physician Phone #: __________________
Diagnosis/Special Needs_______________________________________________________
Are all of your child’s immunizations up to date? Yes/No
Does your child use medication? If so, what kind(s) and what are they used for?
___________________________________________________________________________
___________________________________________________________________________
Emergency Contact Information
Emergency Contact #1:______________________ Relationship:___________________
Home Phone:_______________ Cell:_________________ Work:____________________
Does this contact have daytime transportation? (circle one) Yes No
Emergency Contact #2:______________________ Relationship:___________________
Home Phone:_______________ Cell:_________________ Work:_____________________
Contact #2 MUST have daytime transportation if Contact #1 Does Not
To ensure that we provide the best possible support, please identify any of the following that
apply to your child:
 Behavioral Concerns
Disruptive Behaviors Yes
 No
If yes, please explain (yelling, swearing,
screaming, spitting, verbal threats,
slamming doors/items, flops on floor,
shuts down, runs off)
Aggressive Behaviors Yes
 No
If yes, please explain (hitting, biting,
kicking, scratching, pull hair, slam
doors/items, throw items, head butting)
Self Injurious Behaviors Yes
 No
If yes, please explain (scratching, pulling
out own hair, bites self, hits self)
 Dietary Restrictions
 Vision/Hearing
 Mobility
 Allergies
 Bowel/Bladder
 Comprehension
 Communication
Please provide a description for any items checked above:
________________________________________________________________________________
________________________________________________________________________________
Application for Camp Success 2015
Please complete application & return to Amy Haid by April 25, 2015
1405 Shady Avenue, Pittsburgh, PA 15217 * Fax 412.420.2143 * aeh@the-institute.org
Please provide suggestions for supporting your child if a behavioral issue should arise:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Additional Information
Will your child need transportation? ___________________________________________
Can you provide transportation if transportation is not provided? ___________________
What are your goals for your child to work toward at Camp Success? _______________
__________________________________________________________________________________
Additional Comments/Concerns: _____________________________________________
________________________________________________________________________
How did you hear about Camp Success?_______________________________________
Are you a client of Project STAR at The Children’s Institute? Yes No
If NO, what organization recommended Camp Success to you?
______________________________________________________________________________
Preferred Camp Session (Circle One)
June 24nd-July 9th (except for July 4th) OR
July 15th-July 29th
Will your child be able to come to all days of camp in their session? Yes
No
Camp Success at The Children’s Institute respects the privacy and security of all information provided within this
application/release. No information will be released to an outside entity with the exception that necessary medical
information may be disclosed in order to ensure proper medical treatment in an emergency. This statement is
provided to assure the parents/guardians of Camp Success participants that the information they provide is
considered private and will not be shared with any other business or medical entity, except as stated above.
Parent/Guardian Signature: _______________________________________
Date Signed: ____________________________