Stepping Forward Counseling Center, LLC
Therapeutic Summer C.A.M.P.
Clinically Advanced Multi-Modality Program
 

Application for: *
 
Contact & Background Information
Child Lives With *
 
Parent/Guardian 1 Information:
 
Parent/Guardian 2 Information:
 
Persons to be Contacted in Case of Emergency If Parent/Guardian Cannot Be Reached:
 
Emergency Contact 1
 
Emergency Contact 2
Special Requests:
 
Please list ALL allergies and special dietary needs that pertain to your child
Medications:
 
Please list ALL medications that have been prescribed to your child
Day Camp Dates (CHATHAM, NJ): Please select the dates your child will be attending
Day Camp Dates (YORBA LINDA, CA): Please select the dates your child will be attending
Day Camp Dates (IRVINE, CA): Please select the dates your child will be attending
*Longer Days
-Please note that there are no sessions on the following dates: July 4th.
-Please note pick up times may vary, so please check the field trip schedule.
 
Additional Services:
 
Please check services required for your child (additional fees will apply)
Early drop off ($10/hour, 8:00AM-9:00AM) *
Late pickup ($10/hour, 4:00PM-6:30PM) *
T-Shirt Information
 
Please check size for the FREE T-Shirt for Summer of 2018 (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. Client is ultimately responsible for payment of all charges identified as “due amounts” which include: insurance payments forwarded to client; 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 client's insurance provider. Failure to pay insurance proceed received by member shall be subject to collection by SFCC with 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 $225.00 to $65,000.00 and may be supplemented by 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
IEP
Insurance Information
 
Please submit insurance information ASAP
 
 
Credit Card / Check Information
 
Please note that the $300.00 non-refundable processing fee must be included with the application.
Enclosed is my *
Billing Address
 
 
Enrollment Questionnaire-Counselor's Insight
Please Provide the Important Information Below:
16. What is the swimming experience for your child? Select one.
 
*Decision for formal enrollment to program is based upon personal interview, observation and review of supportive information, after receiving the completed application and processing fee of $300.00. Please call Stepping Forward Counseling Center, LLC at (973) 635-6550 as soon as possible to set up an appointment.
                                              
 
                                                    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 *
Stepping Forward
Counseling Center, LLC
Therapeutic Summer Camp
Medical Treatment Consent Form
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
Child Immunization Record
*To be completed by Physician's office.
 
MEDICAL CONTACT INFORMATION
 
HEALTH COMMENTS
Diet:
Diabetes:
Asthma
 
VACCINE
Provisional Admission:
Medical Exemption:
Religious Exemption