Referral Form 2025

REFERRAL FORM 2025

PLEASE READ THIS GUIDANCE BEFORE COMPLETING THE FORM:

Please note you can also self refer to our services and a staff member will call you back.

Essential Criteria for Residential Camps:

We invite applications from children ages 8 to 17 years, living in the the UK, who are currently experiencing health challenges or have finished treatment in the last 3 years.

To ensure the child is able to benefit fully from our camp programme, they must:

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 verbally communicate their needs independently.
Be able to transfer between floor, bed and chair without assistance if they use a wheelchair.
Be able to attend to their own personal care.

Unfortunately, we are unable to accept campers for Residential Camp who:

Require significant assistance with toileting/bathing.
Require frequent rest periods/naps during the day, resulting in missing a significant amount if the scheduled activities.
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.
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 a ketogenic diet or a specific medical diet, such as a low protein diet.
Are currently experiencing suicidal thoughts or self-harming.

Essential Criteria for Camp in the Cloud (Virtual Camp Programme):

Families with a child or young person aged from 0-17 years, who is currently experiencing health challenges or has finished treatment in the last 3 years. One child in the family must be aged 6 to 17 years.

Included in the Seriously Fun Box is a variety of activities including some arts and crafts whoch will requie th use of scissors and fine motor skills and for some children and young people assisstance may be required from an adult.

If you have any questions or concerns regarding the applicant or process, please contact us on 02392 477110 option 1 or campers@otw.org.uk. This form can be returned by email or post, please see the end of the form for details.

Please select the box to show that you confirm that the child meets our criteria *

YES, I confirm that the child/ young person meets the camper criteria as outlined aboveNO they do not meet criteria. Please return back to OTW

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? (If through the RCPCH Conference please note this in the box below)*

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 NameLast Name

Relationship to child/ren*

Phone Number*

Email

example@example.com

Title

Full name*

First NameLast 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.

If the heath challenge child would like to be in a team with another camper, please put the other camper's name here. We will try our best to put them in the same team at camp.

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

We will also add your contact 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)