Health Care Professional Referral Form 2022

Please read the essential requirements to ensure the child is suitable for camp:

Essential Requirements

Camp in the Cloud (Virtual Camp Programme):

Family Camp
For family camps children aged from birth to 17 years can attend and one child in the family must be aged between 6 to 17 years.
Camp in the Cloud has a varietyof activities including some arts and crafts which wll require the use of scissors and fine motor skills and for some children and young people assistance may be required from an adult in the hosue.
Unfortunatley we are unable to take campers who are currently a hospital inpatient.

Residential Camps:

For family camps children aged from birth to 17 years can attend and one child in the family must be aged between 8 to 17 years.
For health challenge and sibling camps the child/ren must be between the ages of 8 to 17 years.
Have the physical ability to participate in an action-packed activity programme with a range of high and low energy activities. Please discuss with us if the child needs adaptations
Have the social and emotional ability to participate in a group setting and team activities with children of their own age
Be able to verbally communicate their needs independently
Be able to transfer between floor, bed and chair without assistance if they use a wheelchair.

Unfortunately, we are unable to accept children who:

Have learning, behavioural or social communication needs that would prevent them from participating in age appropriate group activities
Are more than 3 years off treatment, if they do not have any ongoing health challenges
Are currently experiencing suicidal thoughts or self-harming

Unable to accept campers for Residential Camps but they can attend Camp in the Cloud:

Need planned overnight care/intervention/monitoring, or health care needs that require constant one-to-one support
Have Cystic Fibrosis or Primary Ciliary Dyskinesia (due to the risk of cross-infection and infection to immunocompromised campers)
Are on the ketogenic diet or a low protein diet

Family Surname *

Has the child attended an OTW camp before? *

If the family are associated with one of our partner charities please identify who:

How did you hear about us? *

Name of the child/children you want to refer:

	Full Name	Age	Gender	Does this child have a Health Challenge- Yes/No?
1
2
3
4

Primary diagnosis of child/children with health challenge: *

Anything else you would like to tell us?

Full name *

First Name Last Name

Relationship to child/ren *

Phone Number *

Email

example@example.com

Title

Full name *

First Name Last Name

Hospital or Organisation *

Position *

Phone Number *

Mobile Number

Email address *

By submitting this form you are confirming that you have sought permission from the family to share their data with Over The Wall.

Thank you for referring to Over The Wall. Our Camper Recruitment team will be in touch with the family.

We will also add your contcat details to our database to keep you updated about our services. If you would like removing from this please just email campers@otw.org.uk.

If you have any questions please contact the office on 02392 477110 or campers@otw.org.uk

Over The Wall

Langstone Technology Park

Langstone Road

Havant

Hampshire

PO9 1SA

Charity No 1075361 & SCO43191

Parent/Guardian Details

Referrer Details (your details)