Health Care Professional Referral Form 2021

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 virtual 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 team activities with children their own age
- have the social and emotional ability to participate in team activities with children of their own age
- be able to communicate their needs independently
- be able to use technology independently.
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
- are currently experiencing suicidal thoughts or self-harming.
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?
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 *
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.
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: