Personalized Supports SOAR thru Summer Application
SOAR Fox Cities: Main Office: 211 E Franklin St., Appleton, WI 54911 SOAR Youth Hub 122 E. College Ave., Suite 201, Appleton, WI 54911
Application Deadline April 20
SOAR thru Summer Personalized Supports will utilize a best fit application process. We do NOT use first come first serve. Please watch the mail in late April for a letter with registration status indicated.
Youth Name
*
First Name
Last Name
Youth Date of Birth - Must be under 18 at time of camp attendance
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Non-Binary
Prefer Not To Answer
Youth Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Youth Ethnicity
*
African American/Black
Caucasion/White
Native American
Alaskan Native
Asian/Pacific Islander
Hispanic
Unspecified
Other
Parent/Guardian #1 Name
*
First Name
Last Name
Relationship to youth
*
Mother
Father
Grandparent
Guardian
Other
Parent/Guardian #1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian #1 Mobile Phone Number
*
Please enter a valid phone number.
Parent/Guardian #1 Second Phone Number
Please enter a valid phone number.
Parent/Guardian #1 Email
*
example@example.com
Parent/Guardian #1 Place of employment if applicable
Parent/Guardian #1 preferred Communication Method
*
Email
Phone
Text
Parent/Guardian #2 Name
First Name
Last Name
Relationship to Child
Mother
Father
Grandparent
Guardian
Other
Parent/Guardian #2 Address - leave blank if same as Parent/Guardian #1
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian #2 Mobile Number
Please enter a valid phone number.
Parent/Guardian #2 Second Phone Number
Please enter a valid phone number.
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 preferred way of communication.
Email
Phone
Text
Which parent/guardian should staff contact first while programing is in session?
*
Please Select
Parent/Guardian #1
Parent/Guardian #2
Acknowledgement and Permissions
Available upon request.
Hold Harmless agreement: I indemnify and hold harmless SOAR Fox Cities, any of its employees and/or agents from all claims from my use of SOAR property or participation in any programs. I will further indemnify and hold harmless SOAR Fox Cities, its employees and/or agents from all costs, expenses and liabilities resulting from any claim brought from my child(ren)’s use of SOAR property and/or participation in SOAR programs to the extent of SOAR's liability under general law.
*
Yes
No
Admission: Parents must share significant medical, physical, or behavioral needs at the time of application. Should there be a significant behavior situation, SOAR thru Summer staff reserve the right to have a youth return home. SOAR thru Summer Personalized Supports will provide a 1:1 ratio.
*
Agree
Disagree
Image Authorization: I authorize SOAR Fox Cities to use any photographs or videos taken of my child for promotional reasons including website, social media, brochures, flyers or newsletter.
*
Yes
No
Late Pick Up: The hours of operation for SOAR thru Summer are 9am through 3pm, Monday through Friday. Pick up and drop off can be flexible within this time frame. A late fee of $15.00 per 15 minute increment will be charged after 3:00pm. Our policy will be to round up so if you pick up your child at 3:10pm you will be charged a $15.00 late fee; If you pick up your child at 3:18pm you will be charged $30.00. The late fee is due before drop off on the next day of care. We reserve the right to bill third party payees.
*
Agree
Disagree
Sunscreen/Insect Repellent permissions: can be applied by
*
SOAR thru Summer Staff
Self
Not Authorized
I give permission for my youth to participate in the following activities:
*
Walking Field Trips
Transportation Field Trips
Other Activities
None
My youth's swimming ability is....
Please Select
Swim deep
Swims shallow
Wades
Fears Water
My youth has permission to receive temporary tattoos or face paint when provided during programming.
*
Yes
No
Only Tattoos
Only Face Paint
***PARENT/GUARDIAN MUST OBTAIN AUTHORIZATION!*** We can accommodate waiver (CLTS, Lakeland, etc.) billing. Please reach out to your case manager for authorization. Once authorization is received, provide us the name and contact information of your consultant, participation ID number or MCI number, and a copy of your authorization so we can set up billing. Send all information to Amay Forbush: amay@soarfoxcities.com. Waivers cannot be billed in advance. If your child misses (without cancellation) a week of programming, you will be responsible to pay the fee. Cancelation Policy: Any weeks that need to be canceled must be done with two weeks notice. Please submit any cancelations in writing to lisa@soarfoxcities.com.
*
Agree
Disagree
County Being Billed for Service
*
Case Manager Name
*
Case Manager Email
*
Case Manager Phone
*
Emergency Contacts
Following Individuals are authorized to help when parents can not be reached including emergency situations.
Non Parent/Guardian Emergency Contact #1 Name - In the event Parent/Guardian can not be reached.
*
First Name
Last Name
Emergency Contact #1 Primary Phone
*
Please enter a valid phone number.
Emergency Contact #1 Secondary Phone
Please enter a valid phone number.
Emergency Contact #1 Authorized To Pick Up
*
Yes
No
Non Parent/Guardian Emergency Contact #2 Name - In the event parent/guardian can not be reached.
*
First Name
Last Name
Emergency Contact #2 Primary Phone
*
Please enter a valid phone number.
Emergency Contact #2 Secondary Phone
Please enter a valid phone number.
Emergency Contact #2 Authorized To Pick Up
*
Yes
No
I understand that ONLY persons on the “Authorized Person(s)” list will be allowed to pick up my child and that they and will be required to present photo identification until staff recognizes parent/guardian/emergency contact before my child is released. Should someone else need to pick up my child, the parent/guardian must provide written notification. This person will need to show photo identification at pick up as well.
*
Agree
Disagree
Medical Information
I authorize SOAR Staff to obtain emergency medical care including transportation for my child to a hospital or other medical facility.
*
Yes
No
Physician Name
*
Physician Phone
*
Cognitive Functioning: check all the apply
*
Cognitive Disability level Mild
Cognitive Disability level Moderate
Attention Deficit Disorder
Mental Health Issues
Autism
Down Syndrome
Other
If other, explain
Physical Conditions: check all that apply
*
Spinal Cord Injury
Visual Impairments
Cerebral Palsy
Stroke
Heart Condition
Epilepsy/Seizure
Asthma
Other
None
If yes to Epilepsy, please give details of type, frequency, date of last seizure and treatment preferences.
If other, explain
Specify Food Allergies: if none, write NKA (no known allergies)
*
Specify Non-Food Allergies: if none, write NKA (no known allergies)
*
Eating
*
Difficulty Chewing
Choking risk
Stuffs Mouth
Portion Control
Help Cutting Food
None
Bathroom/Toileting - Youth must be mostly independent in the restroom.
*
Independent
Needs Reminders
Timed Bathroom Breaks
Full assistance with changing
Socialization
*
Social
Complaint
Helpful
Withdrawn/shy
History of Elopement - running from a location
Self Abusive
Clings to Opposite sex
Verbally Aggressive
Physically Aggressive to other
Physically Aggressive to objects
Other
Triggers: Please list any triggers for behaviors.
*
Explain: Give as much detail as possible, this is very helpful to summer staff. Please share any behavior plans you use at home as well.
*
Likes: Please tell us a few things your youth likes, things that help if they are upset or favorites of theirs.
*
Weekly Options
Indicate all weeks youth is applying for. Check all that apply. NOTE: SOAR thru Summer Personalized Supports will use best fit process. If a week is on waitlist, it is because the deadline has passed and we are giving priority to those applications.
Full-Capacity weeks- ATTENTION APPLICANTS: We have received a high number of registrations, resulting in weeks being at FULL capacity. You are still welcome to apply and be added to the waitlist, as this is a "best fit" program. Please keep in mind that there is a limited number of spots available, as a result, the chances of securing a full summer of support is low. We apologize for any inconvenience. The following weeks have received 15 or more applications, putting the program at full capacity. Please still indicate if you are interested in these weeks, as we are a BEST FIT, not first come program.
June 23-27
June 16-20
June 30-July 3
July 7-11
July 14-18
July 21-25
July28-August 1
August 4-8
August 11-15
Notification of Weeks
Please watch the mail for a letter in late-April that will indicate which weeks your youth is confirmed for. This letter will also have details about how to access our space and need to knows for the program.
ANY CHANGES TO REGISTRATIONS MUST BE SUBMITTED TO Lisa McCallister. Lisa@soarfoxcities.com
I Understand
Signatures
Parent/Guardian Signature
*
Registration Date
*
Submit
Should be Empty: