Camp SSTAR 2010 Application

You can either complete the online application below, or download and mail the application to:

  Connie Coulter-Erbert
Director of CARE and Autism Outreach
8700 East 29th Street North
Wichita, Kansas 67226

Acceptance for the camp will not be based solely on a "first come first served" basis. Other considerations include: the availability of slots, the best available candidate (i.e. match) for a particular group or activity, as well as the identified need as expressed by the parent specific to social skills deficits and challenges, and the sincere desire of the child to attend Camp SSTAR.

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Child Information

• * Did your child attend Camp SSTAR last year? Yes No
• Full Name:
  • First
  • MI
  • Last
  •  
• Address:
  • Street
  • Apt #
  • City
  • Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusettes Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State
  • Zip Code
• Telephone:
• Date of Birth:
• Age:
• Gender: Male Female
• Primary Language:
• Type of Communication System:

Parent/Guardian Information

• Child lives with: -- select -- MotherFatherBothSplit/joint CustodyOther
• If other:
• Parent/Guardian #1
  • * Full Name:
  • Relationship:
  • Legal Guardian
  • * Email:
  • Home Address:
  • Business Name:
  • Hours at Work:
  • Business Address:
  • Business Phone:
  •  
• Parent/Guardian #2
  • Full Name:
  • Relationship:
  • Legal Guardian
  • Email:
  • Home Address:
  • Business Name:
  • Hours at Work:
  • Business Address:
  • Business Phone:
  •  
• Siblings at home (first name, gender & age):

School Information

• Current School:
• Location:
• Current Grade:
• Does your child receive special education services? Yes No
• What kind of supports, if any, does your child receive at school? (For example, occupational therapy, speech, and language therapy, social skills groups, learning center support, in-school counseling, modified behavior plan, 1:1 teaching assitant, reduced class size, adaptive PE, etc.)

Medical Information

• Child's Physician:
• Location:
• Health Conditions:
• Allergies/Diet:
• Is your child currently taking any medication? (Note: medications will not be administered at camp. Please plan accordingly.)
• Special limitations or concerns:

Developmental Information

• What are your child's strengths & interests? (Please be specific.)
• Does your child have a diagnosis of Asperger's Syndrome or High Functioning Autism? (Please list other diagnoses in addition to the Asperger or HFA diagnosis.)
• Please describe your child's learning style:
• What interventions or services have been helpful in meeting the needs of your child? (Please include any behavioral challenges as well as a copy of current Behavioral Intervention Plan if applicable.)

Comments

• How did you hear about us or who referred you?
• Please include any comments or additional information you have about your application.
• Please leave this field blank:

Photograph, Videotape and Information Release Consent

• * As the parent/guardian/power of attorney of this child, I give Heartspring permission to use video recordings and/or photographs of the individual named above, as well as any correspondence I share with Heartspring staff, including testimonials, for production of educational or promotional materials, publications, Heartspring Web sites and/or releases to the news media that may be viewed by the general public. I understand photographs of the child named above may be used even upon completion of services. Yes No
• * Permission is given to use the child's name as follows: First name only No name
• * I also agree that characteristic, diagnostic, and other information about the child named above may be used in educational or promotional materials, publications, Heartspring Web sites and/or releases to the news media that may be read by the general public. Yes No
• * I hereby give Heartspring permission to release my name, address, e-mail and/or telephone number to other families who might wish to contact me regarding Heartspring. Yes No
• * In an effort to share with Heartspring patron organizations how their financial support is used by Heartspring, I give permission to share the information outlined above as requested for patron newsletters, stewardship reports, and/or proposals for additional funding. Yes No
• * I recognize that Heartspring often receives requests from parents for information regarding their child’s program at Heartspring, such as photographs, video recordings, and other documentation relating to Heartspring activities. I give permission for such documentation that includes the child named above to be shared with other Heartspring parents. Yes No

• It is important that you fully provide the information that we request so that we can assess and address your child's needs as effectively as possible. Withholding of pertinent information can not only jeopardize your child from receiving the best care possible, but also hinder our ability to handle any challenges or crises that may arise.
• I/We hereby make an application and give permission for my child/ward to attend Camp SSTAR. I/We have filled out all information to the best of my/our knowledge.*
• * Denotes required field.

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