Camper Registration of Interest 2021

Referral Form 2021
Name

First Name Last Name
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- Please read the essential requirements to ensure the child is suitable for camp -
Essential Requirements

To ensure the child is able to benefit fully from our camp programme, they must:
- for health challenge and sibling camps the child/ren must be between the ages of 8 to 17 years
- 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
- have the physical ability to participate in an action-packed activity programme with a range of high and low energy activities
- have the social and emotional ability to participate in a group setting and team activities with children of their own age
- be able to communicate their needs independently
- be able to transfer from chair to floor and floor to 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 2-3 years off treatment, if they do not have any ongoing health challenges
- need 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
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 child with health challenge:

Full Name

Age

Gender

Primary diagnosis of child with health challenge: *
Parent/Guardian Details
Full name *

First Name Last Name
Relationship to child/ren *
Phone Number *
Email
example@example.com
Referrer Details (your details)
Title
Full name *

First Name Last Name
Hospital or Organisation *
Position *
Phone Number *
Mobile Number
Email address *
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Thank you for referring to Over The Wall. Our Camper Recruitment team will be in touch with the family.
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
Should be Empty:

Referral Form 2021

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Parent/Guardian Details

Referrer Details (your details)

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