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CHILD APPLICATION

SUMMER 2017

PROGRAM DATES: JUNE 26th - AUGUST 4th, MONDAY-FRIDAY

ABOUT RAY OF HOPE

Ray of Hope Summer Day Program is a six-week program for children ages 5-12 with emotional, behavioral, and/or economic challenges. It is a day program unlike any other offering arts and crafts, recreation, field trips, and artistic enrichment. Ray of Hope strives to introduce empowering social skills and inspiring life principles through story and relationship. Ray of Hope is for the kids who most need, yet seldom experience, such a holistic, well staffed, and fun summer.



CHILD APPLICATION DEADLINE: May 12th, 2017


Office Use Only


Date Application Received:

 

316 E. McLeod Rd, Suite 102



Bellingham, WA 98226

Phone: 360-714-0700



Fax: 360-714-0704

APPLICATION INFORMATION SUMMER PROGRAM 2017


Ray of Hope 2017 Details
Where: Silver Beach Elementary, 4101 Academy St., Bellingham, WA 98226

When: June 26th – August 4th, Monday – Friday 9am – 3pm (Extended Care Available)

Cost: $1,200 per child for entire summer (Includes $50 registration and $35 field trip fee)
Ray of Hope is a licensed childcare provider pursuant to WAC 170-290-0125, eligible for childcare assistance benefits; childcare provider number is pending.


A Day at Ray of Hope

Morning Session: The morning starts with breakfast where announcements are made and super green badges are awarded. Children and leaders are then dismissed for small group time. During small group time, campers explore social skills and life skills including positive choices, expressing feelings, peer pressure, and caring for one another. Kids explore the themes of excellence, empowerment, self-control, teamwork, kindness and hope. After small group time, campers participate in artistic and recreational activities with lunch following.
Afternoon Activities: In the afternoon, groups participate in either a field trip in Whatcom County, enrichment activities led by community members, or swim time at Lake Samish. These activities are opportunities for kids to build positive relationships in a fun and creative context. The day ends with “Highlights”, where all campers celebrate moments of camp spirit. The kids then transition into their respective pick up and transportation groups to get home after a full day at camp.

Application Directions


  1. Complete the following application information by filling appropriate answer spaces and by marking check boxes.




  1. Review each section of the application to ensure your application is 100% complete.


  1. Return your completed application to Rebound of Whatcom County using one of the following methods:

  • By Mail or Drop Off: 316 E. McLeod Rd Suite 102 Bellingham WA 98226

  • By Fax: 360-714-0704


RAY OF HOPE CHILD APPLICATION CHECKLIST:
There are a limited number of spots available at Ray of Hope each summer. Due to recent staff changes, we are only able to accept a maximum of 70 kids this summer. The successful completion of your child’s application will ensure that it will be processed in a timely fashion. If any part of the Ray of Hope child application is not filled in, we will consider the application incomplete and may affect your child’s opportunity to attend Ray of Hope. Please take a moment and review this checklist to ensure you have completely filled out ALL sections of the application and attached the appropriate documents.
If you have more than one child that you are applying for, please complete an application for EACH child, we are not able to transfer information from one application to another, even if the information is the same.
RAY OF HOPE PAYMENT OPTIONS (Page 4)

  • Select appropriate payment option.

  • If necessary, attach any documents as requested to your child(ren)’s application.

  • Call for verification or qualification as needed.
  • If applying for a partial scholarship, please call the Rebound office at 360-714-0700 to request an application and it will be sent to you. Please do NOT turn in your child application without attaching the scholarship application to it. Your application will be considered incomplete if you check the scholarship application option without attaching it.



CHILD REGISTRATION (Page 5)

  • Double check that every box and line is filled in, write “N/A” if a particular section does not apply.


EMOTIONAL/BEHAVIORAL HISTORY (Page 6-7)

  • To best serve your child, please fill in this section with as much information as possible so we can provide a safe and successful summer for your child.

  • Include a copy of your child’s IEP or any behavior plan they are currently on at school.


MEDICAL INFORMATION (Page 8)

  • Fill out complete information about your child’s medical history and needs.

  • Sign and date at the bottom


RELEASE OF CONFIDENTIAL INFORMATION (Page 9)

  • Please fill this form out completely. It may contain information you have already provided however we need it on this form also.

  • Sign and date at the bottom


ADDITIONAL RAY OF HOPE SERVICES (Page 10)

Transportation

  • Please only request transportation services if you are unable to transport your child to and/or from Ray of Hope each day. We have limited transportation routes. Please indicate Yes or No on the application.

Extended Care

  • Please indicate Yes or No on the application.


DECLARATION, INCOME STATEMENT, IMMUNIZATION RECORDS (Page 10-12)

  • Be sure and sign and date this portion so we know who has completed the application and how best to reach you.
  • Please completely fill out the income statement, we are required by the state to have a form for every child.


  • Immunization form – we need every child’s immunization records filled out on this specific form, we cannot accept other forms from medical providers.


RAY OF HOPE TUITION PAYMENT OPTIONS
Child’s Name:

 

Parent/Guardian’s Name:

 

The total cost of tuition for Ray of Hope is $1200 per child for the summer, including a $50 registration fee and $35 field trip fee.



Please select one of the following payment options. If options 1-3 do not apply, choose option 4 or 5.

 

Option 1: WASHINGTON STATE CHILDCARE BENEFITS (Working Connections Child Care or Seasonal Child Care)



 

If the child’s parent/guardian’s income qualifies AND one of the following is true, you MAY be able to receive childcare benefits from Washington state that can be designated to pay for most of the child’s tuition at Ray of Hope:

  • Works outside the home or is self-employed,

  • Attends school or job training,

  • Is part of “Working Connections” or “Work First”

  • Is a seasonal agriculture worker,

  • Has a child with special needs.

  • Is homeless, lives in transitional housing, or lives temporarily with family or friends

□ I am approved for Washington State childcare benefits (Attach a copy of your award letter with this application)


  • Client Identification Number (Not TANF number)

□ I want to find out if I qualify for Washington State Childcare Benefits.



  • Apply immediately by calling 1-877-501-2233 or going online at www.washingtonconnection.org.

Option 2: DIVISION OF CHILD AND FAMILY SERVICES (DCFS or CPS)


If the child is in state-appointed care, they MAY qualify for childcare assistance benefits to apply to Ray of

Hope tuition through the Division of Child and Family Services (DCFS) or Child Protective Services (CPS).

Contact your DCFS/CPS caseworker to verify before submitting this application. You will need to tell them Ray of Hope’s state provider number is 1066259. Once verified, complete the following:

____________________________________ _______________________

Name of Social Worker Date of Verification

 

Option 3: DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA)


If the child has a developmental disability (physical or intellectual delays, including autism spectrum), they MAY qualify for tuition reimbursement from the Developmental Disabilities Administration (DDA). To see if you qualify, contact the local DDA office at 360-714-5000.

□ My child has already been approved for DDA benefits (Attach a copy of your approval document with this application)


Option 4: I WILL COVER TUITION IN FULL.

  • We offer flexible payment plans and payment schedules. We will contact you to set up a payment agreement.

Option 5: I WOULD LIKE TO APPLY FOR A PARTIAL SCHOLARSHIP.


  • We accept a limited number of Ray of Hope students on partial scholarship. All partial scholarships are available on a first come, first serve basis (with some exceptions). Scholarship applicants will need to complete an additional scholarship application and provide income verification as requested. Please request a scholarship application by calling or emailing Shelli Wood at 360-714-0700 x4 or shelli@reboundfamilies.org and one will be sent to you. Please DO NOT turn in your application without attaching the scholarship application.


CHILD REGISTRATION (PLEASE PRINT)

 

Child’s Name:

First Name Last Name
Child’s Birthdate: Child’s Gender (circle): Male Female

Month/Day/Year



PARENT/GUARDIAN INFORMATION
Parent/Guardian Name (Adult Living with Child):

Relationship to child (circle): Parent Foster Parent Relative/Other (specify):

(Grandparent, Aunt, Friend, etc.)


Phone Number: _________ Alternative Phone Number: ____________ Verified #’s_________________

 

Email address (include only if checked regularly):

 

Address:

Street City/State/ZIP


CHILD INFORMATION
Past Rebound of Whatcom County Programs Attended:

Ray of Hope Roots Other Rebound program None

Year(s) Year(s) Year(s)
Does child/family have a case worker through any of the following agencies? Yes No

□ DCFS (Division of Child and Family Services) □ CCS (Catholic Community Services)

□ DSHS (Department of Social and Health Services) □ Opportunity Council

□ Lummi Children’s Services □ Other:


Case Worker Name: Phone #:
Agency: Email Address:
Ethnicity (circle at least one):

Asian Black/African-American American Indian/Alaskan Native

White/Non-Hispanic Hispanic Native Hawaiian/Pacific Islander

  Other:

 
Please list any of the child’s ongoing physical conditions:

School(s) Attended September 2016 - June 2017:

 School Attending Fall 2017: Grade Fall 2017:

 

 At school, does child currently have (circle): IEP Behavior Plan One-on-One Aide 504 Plan


EMOTIONAL & BEHAVIORAL HISTORY (pg.1)
CHILD NAME: ___________________________________________

 

Accurate information in the following section greatly impacts a child’s success at Ray of Hope. It is vital in helping staff better serve the children during the program. Please be as accurate as possible.


1. What are some positive factors that are an important part of this child’s life? (check all that apply)

□ Caring School Environment

□ Positive Adult Role Models

Supportive Family Members

□ Healthy Friendships with Peers

□ Desire to Help Others

□ Safe Home Environment

□ Creativity

□ Enjoyment of Learning

□ Good Self Esteem

□ Avoiding Unhealthy Peer Pressure

□ Achievement in School

□ Sense of Humor

□ Involvement in a Faith Community

□ Important Sibling Relationships

□ Hope for their Personal Future

□ Other(s):






2. What are some of this child’s strengths and interests?


3. What things have helped this child overcome difficult situations?


4. Has this child ever demonstrated any of the following behaviors? (check all that apply)

□ Physical Aggression (Hitting, kicking, biting, etc.)

□ Verbal Aggression (Swearing, threatening, shouting, etc.)

□ Difficulty sitting still/paying attention

□ Difficulty with change/transitions

□ Low Self-Esteem

□ Withdrawn

□ Defiance

Bullying

□ Running Away

□ Tantrums

□ Lying

□ Stealing


□ Eating Disorder

□ Sexual Acting Out

□ Toileting Accidents


5. What are some challenging behaviors that this child shows currently (within the last 3 months)?


6. What types of situations have led to behavioral escalations from this child?


EMOTIONAL & BEHAVIORAL HISTORY (pg.2)
7. Please indicate to the best of your knowledge all of the following that apply:


My Child:

 

□ Takes medication



□ Has been hospitalized (emotional, behavioral, and/or psychiatric reasons)

□ Has been in foster care

Is currently in foster care

□ Has witnessed abuse

□ Has been a victim of abuse

□ Has been exposed to drug/alcohol abuse

□ Has a family member in prison

□ Lives with a family member with mental illness


 Within the Last Year:
□ Has lost a family member

(death, divorce/breakup, prison, moved away)

□ Has gained a family member

(new baby, marriage/partnership, adoption)

□ Has changed caregivers

□ Has experienced housing instability

(homelessness, shelter, transitional housing, etc.)

□ Other:




8. What experiences has your child had that could be important to their Ray of Hope experience?


9. Please indicate to the best of your knowledge all of the following that apply:

Has Been Diagnosed With:

□ ADD/ADHD

Anxiety Disorder

□ Autism/Asperger’s Syndrome

□ Developmental Delay

□ Learning Disability

□ Oppositional Defiant Disorder

□ Sensory Integration Disorder

□ Other:

Has Current*:

*Include any plans with your application.

□ IEP


504 Plan

□ Behavior plan

□ One on One aid in School

 

 



 
Has Been/Is Involved With:

□ An In-Home Intervention

Program (e.g. SWIFT, CHAPS, etc.)

□ School Behavior Program

(e.g. Bridges, Discovery school, etc.)

□ Mental Health Counseling

□ Juvenile Detention

□ Other: ________________



Please provide any important details about any of the above checked boxes:



Please Note: Ray of Hope may request that parents or guardians pursue someone who has worked closely with this child to complete an additional Emotional Behavioral Form (Such as a Teacher, Counselor, School Administrator, Social Worker, or Mentor). Providing this additional information helps staff better serve children during the Ray of Hope program.

MEDICAL INFORMATION

 

CHILD NAME: _________________________________________


 

1. Medical History (Required):

* Doctor’s name: ______________________ Phone: ________________ Last Physical Exam (mm/yy):_________________

* Dentist’s name: ______________________ Phone: ________________ Last Dental Exam (mm/yy):_________________

* Does your child have any allergies? (medicine, food, hay fever, insect bites, etc.): Yes No



Please list:

* Does your child have any illnesses, disabilities or injuries? (physical or mental.): Yes No


Please list:

* Is there a specific camp activity you do NOT want your child to participate in? Yes No


Please state which activity/why:

 

2. Over-the-Counter Medication:

I hereby give Ray of Hope camp staff permission to administer the following products according to manufacturer’s instructions. I trust Ray of Hope camp staff to use their best judgment as situations arise, and, if in doubt, he/she can call for verification.
YES to all items A – O NO to all items A - O

A. Sunblock F Lip Balm K. Cough Syrup

B. Tylenol G. Antiseptic Ointment L. Cough Drops

C. Ibuprofen H. Hydrogen Peroxide M. Decongestant

D. Band-aids I. Rubbing Alcohol N. Antihistamine

E. Insect Repellant J. Anti-Itch Cream O. Ipecac Syrup



3. Prescription Medication:

* Does your child currently take any prescription medications? (list all below) Yes No

* Will Ray of Hope need to administer any prescription medications? N/A Yes No

 

Prescription Medication: Diagnosis for Medication: Administered at Administered at



Ray of Hope Home

_________________________________ ______________________________



____________________________ _________________________

____________________________ _________________________

____________________________ _________________________
4.

Medical Release:

My child has permission to engage in all prescribed program activities, except as noted above. The undersigned do hereby authorize the directors of Ray of Hope camp or such substitute as they may designate as agent for the undersigned to consent to an X-Ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care for the Minor which is deemed advisable by and to be rendered under the general or special supervision of any physician and surgeon, licensed under the provision of the Medical Practice Act or any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, or hospital, camp or elsewhere. This authorization remains effective while the above said Minor is en route to and from or involved or participating in any camp program, unless revoked in writing by the undersigned and delivered to the Ray of Hope program director.

 


_____________________________________________ __________________________

Signature Date

RELEASE OF CONFIDENTIAL INFORMATION

 

Child’s Name: Date of Birth:

Month/Day/Year
If there is any educational information, physical or mental healthcare information, or case information that you want a professional to share with Ray of Hope administrators, please list their contact information in the following areas.
I authorize the exchange of information described below between Rebound of Whatcom County and the following agency(s) and/or individual(s):
School Personnel, Name (Teacher, Counselor, Administrator, etc.):

School Name:

Contact Phone and Email:

Healthcare Provider, Name (Doctor, psychologist, therapist, etc.):

Healthcare Organization Name:

Contact Phone and Email:

Agency Caseworker(s), Name(s) (DCFS, CCS, DSHS, etc.):
Agency(s):

Contact Phone and Email:

Additional Parent/Legal Guardian, Name:
Contact Phone and Email:

Other Contact, Name:

Contact Phone and Email:

This authorization applies to the following circumstances (circle all that apply):

Educational Data/IEP Social/Developmental Psychological Medical Other:


Restrictions: Providers who receive this information may not release it to someone else unless another authorization form is signed.
Parent/Guardian Signature: Date:

Relationship to child:


Expiration: This authorization is valid from date signed until August 4, 2017 (conclusion of Ray of Hope Program).
ADDITIONAL RAY OF HOPE SERVICES

Transportation

Ray of Hope is able to transport a limited number of students to and from the program site.



  • Pick-ups and drop-offs will occur at locations central to the families using transportation.

  • Pick-ups will generally occur between 8:00 and 8:45 AM. Drop-offs will generally occur between 3:05 and 3:45 PM.


I would like to apply for Ray of Hope Transportation for my child. Please Check: □ Yes □ No

Extended Care

For parents who are unable to transport their children for Ray of Hope at 9:00 AM and 3:00 PM, and are unable to utilize Ray of Hope transportation, extended care is available for a limited number of students.



  • Morning extended care begins at 8:30 AM. Afternoon extended care ends at 5:30 PM.


I would like to apply for Ray of Hope extended care my child. Please Check: □ Yes □ No
If you have requested additional services, Rebound will contact you for further information.

DECLARATION

Please review the complete Ray of Hope 2017 child application. By signing below, I certify

that I have completed this application thoroughly, honestly, and to the best of my ability.

I also certify that I am the legal guardian of the child specified, or have been granted authority


by the legal guardian or the state of Washington to complete this application on his/her behalf.

This Application Was Completed By:

Name: Signature: Date:

Relationship to Child: Phone: Email:

All follow up questions/correspondence from Rebound regarding this application should be directed to (circle):

Child’s Legal Guardian Child’s Social Worker Other:



Name Phone
AFTER COMPLETING & RETURNING APPLICATION:
1. Expect a call from a staff person at Rebound of Whatcom County to notify you that this application has been received. You will also receive a confirmation letter from Rebound/Ray of Hope in the mail. The letter may contain further instructions required to continue processing this child’s application.
2. Following the final completion of this application, you will be notified of this child’s placement status into the Ray of Hope program. Thank you.






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