2025 Camper Referral Form

2025 Camper & Family Referral Form

Thank you for trusting Double H as a resource for your patients. Please thoroughly read through our eligibility grid before completing the referral form.

Medically Qualifying Camper Eligibility

	Summer Camp Program	Spring & Fall Family Weekends	Adaptive Winter Sports Program
Qualifying Medical Diagnoses	complete list of summer diagnoses HERE	complete list of spring & fall diagnoses HERE	complete list of winter diagnoses HERE
Age	6-16 years old	5-21 years old	6-16 years old
Cognitive Level	at least 6 years old	at least 5 years old	at least 6 years old
Submitted Forms	Current Physical Exam, Supplemental Medical Forms & Vaccination Record	Current Physical Exam & Vaccination Record	Current Physical Exam & Vaccination Record including the seasonal flu shot

We are unable to safely serve campers who...

Are unable to stay overnight in a room of their peers during summer camp.
Require continuous overnight monitoring such as pulse oximetry during summer camp.
Are elopement risks.
Are currently experiencing suicidal thoughts or self-harming.

Questions?

If you have any questions or concerns regarding camper eligibility or the applciation process, please contact Double H Ranch's Admissions Office.

Tara Bogucki, Admissions Director
tbogucki@doublehranch.org
518-696-5676 x 222

Referrer Information

Please provide your contact for possible follow up.
Your Name*

First NameLast Name
Hospital or Organization*
Title*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Referral Information

Please answer the following questions regarding the child/children you want to refer.
Has this child/children participated in Double H Ranch programs before?

YesNoUnsure
Is the child/children associated with any of our partner hospitals or health organizations?

Name, age, and qualifying status of the child/children.*

Rows	Child's Full Name	Age	Does this child have a qualifying medical diagnosis? Yes or No
1
2
3
4
5

Primary diagnosis of the qualifying child/children.*
Any other information you would like us to know.
Parent/Guardian Full Name*

First NameLast Name
Relationship to Child*
Parent/Guardian Email Address*
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
By submitting this form, you are confirming that...*

I have sought permission from the family to share their information with Double H Ranch.Double H has permission to contact the family directly through the Parent/Guardian contact information provided above.
Should be Empty:

2025 Camper & Family Referral Form