Stepping Forward Summer Application

Attach a recent photo of your child *

Application for: *

Chatham, NJ

Yorba Linda, CA

Irvine, CA

How did you hear about our C.A.M.P.? *

Contact & Background Information

Last Name of Child *

First Name of Child *

Street Address *

City *

State *

Zip Code *

Home Phone *

Date of Birth *

Age *

Gender *

Child Lives With *

Mother

Father

Other

If divorced, or legally separated, who has custody?

Parent/Guardian 1 Information:

Last Name of Parent/Guardian *

First Name of Parent/Guardian *

Street Address *

City *

State *

Zip Code *

Date of Birth *

Home Phone *

Work Phone

Cell Phone

E-Mail Address *

Relation to Child *

Parent/Guardian 2 Information:

Last Name of Parent/Guardian

First Name of Parent/Guardian

Street Address

City

State

Zip Code

Date of Birth

Home Phone

Work Phone

Cell Phone

E-Mail

Relation to Child

Persons to be Contacted in Case of Emergency If Parent/Guardian Cannot Be Reached:

Emergency Contact 1

Name *

Home Phone *

Cell Phone

Relation to Child *

Emergency Contact 2

Name *

Home Phone *

Cell Phone

Relation to Child *

Special Requests:

Please list ALL allergies and special dietary needs that pertain to your child

Medications:

Please list ALL medications and dosage that have been prescribed to your child

Below, please check off the weeks your child will be attending. Please note that a requirement of the program is that your child must be enrolled for at least three consecutive weeks. If your child is signed up to attend the program for nine or more weeks, they will be scheduled to meet with the psychiatrist for a psychiatric evaluation.

Day C.A.M.P. Dates (CHATHAM, NJ): Please select the dates your child will be attending

Day C.A.M.P. Dates (YORBA LINDA, CA): Please select the dates your child will be attending

Day C.A.M.P. Dates (IRVINE, CA): Please select the dates your child will be attending

* Dependent on the number of registered campers

** SFCC will be closed 07/04 for the holiday

- Please note pick-up times may vary, so please check the field trip schedule

- Fridays are early dismissal, pick up is at 1 pm

Additional Services:

Please check the services required for your child (additional fees will apply)

Early drop off ($20/hour, 8:00AM-9:00AM) *

Yes

No

Drop off time

Late pickup ($20/hour, 3:00PM-5:30PM*) *hours vary by location. Check with your location! *

Yes

No

Pickup time

T-Shirt Information Please check size for the FREE T-Shirt for Summer of 2024 (Predict size in summer) Additional T-Shirts may be purchased for $20 each *

FINANCIAL INFORMATION

Published rates are for Cash and Schools only. Other institutions are billed at a higher rate. The client is ultimately responsible for payment of all charges identified as “due amounts” which include: insurance payments forwarded to the client, deductibles, co-payments, intake fees, reinforcement fees, missed appointment fees, application fees, and other fees and costs delineated by SFCC. SFCC shall submit applicable due amounts (identified as “insurance billed amounts”) for reimbursement to the client's insurance provider. Failure to pay insurance proceeds received by the member shall be subject to collection by SFCC with the client being responsible for all costs of collection, including attorney fees. Stepping Forward owns and operates licensed and/or accredited mental health treatment centers and therapeutic summer programs. The length of stay and level of clinical intervention determine the cost of each program. Tuition/fees may range from $400.00 to $65,000.00 and may be supplemented by a sliding scale, insurance, scholarships, or agreements to pay. Many of our programs are contracted with insurance carriers, scholarships, and school programs. Parents are encouraged to contact SFCC directly to request assistance with obtaining payments and insurance coverage.

School Reimbursement

School District Contact

Phone

Fax

IEP

Yes

No

Insurance Information

Please submit insurance information ASAP

Member Name *

Member Date of Birth *

Child's Name *

Child's Date of Birth *

Carrier Name *

Policy Number *

Group Number *

Effective Date *

Insurance Provider Phone Number *

Attach a copy of the front and back of your child's insurance card *

Credit Card / Check Information

Please note that the $400.00 non-refundable processing fee must be included with the application. Your application will not be processed until the fee is received.

Enclosed is my *

Check and/or

Visa

MasterCard

American Express

Amount

Card Number

Security Code

Expiration

Billing Address

Street

City

State

Zip Code

Cardholder's Name

Enrollment Questionnaire-Counselor's Insight

Please Provide the Important Information Below:

1. Case Manager Name/Title (If Applicable)

2. Please describe your child's school setting and goals

3. What is your child's educational classification?

4. What is your child's diagnosis?

Please list and describe your major concerns for your child.

6. Is your child physically aggressive?

6a. Does your child bite?

7. Has your child ever been asked to leave a program? If so, please explain.

8. Do you consider your child more compliant or more oppositional? Please explain.

9. Please describe your child's attention span.

10. Please describe your child's language ability

11. Please name and explain activities and areas of greatest success for your child.

12. Please describe previous summer camp experiences your child has had (be sure to include dates and place/name of camp):

13. Under what circumstances, if any, does your child become stressed or frustrated?

14. Is there a "nickname" your child likes to be called?

15. Is there anything you feel we need to know about your child?

Strengths

Weaknesses

16. What is the swimming experience for your child? Select one.

17. What are your child's fears?

18. Please name activities your child would most enjoy at Stepping Forward

19. Please state YOUR requested goals for your child at Stepping Forward.

*Decision for formal enrollment to the program is based upon personal interview, observation, and review of supportive information, after receiving the completed application and processing fee of $400.00. Please call your local Stepping Forward Counseling Center as soon as possible to set up an appointment (Chatham, NJ: (973) 635-6550 • Yorba Linda, CA: (714) 340-0511 • Irvine, CA: (949) 333-1209).

Parent Authorization

1.     I agree to pay the annual tuition. Pre-payment is due prior to the start of camp. In the event of 3rd party payment all claims are due to Stepping Forward Counseling Center, LLC. In the event a check(s) is/are received from an insurance provider and/or school, it is agreed that said check(s) will be designated as “payable to Stepping Forward Counseling Center” and the check(s) and explanation of benefits will be immediately forwarded to Stepping Forward.

2.     No refunds will be made for incidental absences or after camp has started.

3.     Stepping Forward is not responsible for any camper’s belongings, either lost or damaged, while attending.

4.     If either parent or the emergency contacts cannot be contacted in an emergency, I hereby give Stepping Forward consent to bring my child to an emergency room or medical professional and authorize Stepping Forward to provide consent to secure necessary and proper medical treatment. I hereby authorize and direct Stepping Forward to administer medication as set forth in this application.

5.     Permission is hereby granted to the Director of Stepping Forward to take my child on field trips as part of the regular program.

6.     Permission is hereby granted for photographs to be taken of my child during activities and Stepping Forward has the right to utilize these photographs in promotional materials.

7.     My child has permission to engage in all prescribed program activities, except noted on the required medical form.

8.     Permission is hereby granted to Stepping Forward to transport my child to and from any off-site activities.

9.     Permission is hereby granted to Stepping Forward counselors to apply sunscreen to my child.

CHECKLIST *

Enclose a photo of your child (for safety reasons)

Sign parent authorization and medical consent form

Child immunization record sent with application

Enclose payment of $400.00 to hold spot

Make a copy of application for your records

Record summer program dates on your calendar

Parent/Guardian Signature

Date

Non-Custodial Parent Signature

Date

Child's Name

Stepping Forward
Counseling Center, LLC
Therapeutic Summer Camp
Medical Treatment Consent Form

As the Parent/Guardian of:

I give my consent for Stepping Forward Counseling Center to take any medical emergency treatment precautions necessary in case of injury or illness to ensure the safety of my dependent. I give permission for SFCC to provide first aid, and to contact the Emergency Medical Service to transport my dependent to the nearest hospital in order to treat him/her with serious injury and/or illness while on-site, or on off-site trips.

Signature of Parent/Guardian *

clear

Special Requests

Please list ALL allergies and special needs that pertain to your child:

Child Immunization Record

*To be completed by Physician's office.

Child's Name

Date of Birth

Parent/Guardian Name

MEDICAL CONTACT INFORMATION

Pediatrician Name

Psychologist Name

Psychiatrist Name

HEALTH COMMENTS

Diet:

Diabetes:

Yes

No

Asthma:

Yes

No

If yes, please list special instructions:

VACCINES

Diphtheria, Tetanus, Pertussis (if TD or DT please indicate):

Date Given:

Last Date of Tetanus Shot:

Polio Virus Vaccine:

Date Given:

Pneumococcal Vaccine:

Date Given:

Hepatitis B Vaccine:

Date Given:

Haemophilus B Vaccine:

Date Given:

Varicella (Chicken Pox Vaccine):

Date Given:

Varicella:

Date Given:

MMR (Measles, Mumps, Rubella):

Date Given:

MMR:

Date Given:

COVID Vaccine:

Date Given:

Other:

Date Given:

Provisional Admission:

Yes

No

Date Granted:

Medical Exemption:

Yes

No

Religious Exemption:

Yes

No

Attach a copy of your child's immunization records *

1. 6/24 - 6/28	2. 7/01 - 7/05 **	3. 7/08 - 7/12	4. 7/15 - 7/19	5. 7/22 - 7/26
6. 7/29 - 8/02	7. 8/05 - 8/09	8. 8/12 - 8/16	9. 8/19 - 8/23

1. 6/10 - 6/14 *	2. 6/17 - 6/21	3. 6/24 - 6/28	4. 7/01 - 7/05 **	5. 7/08 - 7/12
6. 7/15 - 7/19	7. 7/22 - 7/26	8. 7/29 - 8/02	9. 8/05 - 8/09	10. 8/12 - 8/16
11. 8/19 - 8/23 *

1. 6/10 - 6/14 *	2. 6/17 - 6/21	3. 6/24 - 6/28	4. 7/01 - 7/05 **	5. 7/08 - 7/12
6. 7/15 - 7/19	7. 7/22 - 7/26	8. 7/29 - 8/02	9. 8/05 - 8/09	10. 8/12 - 8/16
11. 8/19 - 8/23 *

YS	YM	YL	AS	AM	AL	AXL
A2XL	A3XL	A4XL