Brighter Days Therapeutic Summer Program

The Brighter Days Therapeutic Summer Program is a comprehensive support program by ACTION, Inc, running Monday through Friday, 9:00 AM to 3:00 PM. We will provide lunch and snacks each day for all participating children. The dates of summer camp are June 2-27 and July 7-August 1. By enrolling your child, you are agreeing to his/ her participation in therapy, case management, and peer support/ mentoring services designed to foster growth and development in the following areas: self-esteem, self-love, self- control, and emotional regulation. As part of this process, parents will be required to participate in an initial psychosocial session to help us better understand your child’s needs. Additionally, all necessary paperwork will need to be completed electronically, and parents must maintain bi-weekly contact with the treatment team to ensure ongoing collaboration. Please note that these services can begin prior to the summer camp and may also continue after the program concludes, offering ongoing support tailored to your child’s journey.

**You MUST complete one form per student that you are enrolling.

***If your child already receives these services elsewhere, please inquire with us whether they will qualify for participation in our program before completing this form. Send information or questions to sydney@actionky.org.

Student Name*

First NameLast Name

Date of Birth*

MonthDayYear

Grade*

Gender*

MaleFemaleOther

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Parent/ Guardian 1*

First NameLast Name

Phone Number*

Parent/ Guardian 2

First NameLast Name

Phone Number

Do we have permission to text you about your child?*

YesNo

E-mail (please list an accessible email that you will sign paperwork from)*

example@example.com

Emergency Information

Emergency Contact's Name (1)*

First NameLast Name

Relationship*

Phone Number*

Alt. Phone Number

Emergency Contact's Name (2)*

First NameLast Name

Relationship*

Phone Number*

Please include a list of people who may pick up your child from ACTION, Inc (include their relationship to your child and their phone numbers):

Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.

Does the student have any behavior concerns or concerns that you would like addressed in therapy? (This will not affect your child's enrollment- we are here to help!)

Is the student prescribed an inhaler? If yes, please explain any instructions.

Is the student prescribed any other medication? If yes, please list medications. **NOTE: We will not disperse medication to campers during our summer camp hours. If your child must take medication, you will need to bring it to them.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by ACTION, Inc during the selected camp. In exchange for the acceptance of said child’s candidacy by ACTION, INC., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless ACTION, Inc and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against ACTION, Inc, including all staff and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities and other outside activities.

Medical Release and Authorization

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named student. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to ACTION, Inc and its affiliates including Directors and Staff, to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Date*

Date

Signature*

Informed Consent and Acknowledgement

I recognize that ACTION, Inc is offering this summer program as a therapeutic based program, which will include behavioral/ mental health therapy, targeted case management, and peer support/ mentoring services. I hereby give my approval for my child’s participation in any and all activities prepared by ACTION, Inc during Bright Days Summer Program. I also give my permission for ACTION, Inc to bill my child's insurance for these services. I recognize that my child's therapist, case manager, or peer support specialist will follow up with me in-person, by phone, or by email. I acknowledge that, to continue these services, I will need to try my best to respond in a timely manner and accept recommendations from treatment providers to assist my child with any concerns or needs disclosured during services. ACTION, Inc is not a daycare or childcare facility and will not be acting as such. Services will be offered to students with the expectation that their family's maintain active Medicaid during their enrollment in the summer program. I also acknowledge that I am giving my child permission to participate in daily group therapy sessions, which will include activities such as crafts, sports, games, and other hobbies, focused on self-esteem, emotional regulation, self-love, and self-control.

Date*

Date

Signature*

Your printed name*

My child has active Medicaid:*

YesNo (sorry- our summer program is for Medicaid clients only)

Please include MCO (Passport, Aetna, Humana, Wellcare, etc)*

Please provide us with your Medicaid ID or Member ID (it is ok if you do not have this right now, but this will be required for enrollment)

Check all that apply:*

My child will attend camp 5 days per weekMy child will attend camp in both June and JulyMy child will attend summer program less than 5 days a weekMy child will attend in June onlyMy child will attend in July only

Is there anything else that you think we need to know about your child before he/she is enrolled in our summer program? Do you have any questions?

What's Next?

If you are already an ACTION client: you are ready to go! See you at 9 AM on June 2nd!

If you are new to ACTION, Inc: In the next 48 hours, you will receive an email from "Therapy Portal." You will create a password and sign initial paperwork here, including HIPAA forms and consent to treat. You can also see the services your child receives here, and update any additional information, at any time, when needed. Following your signing of paperwork, you will be contacted by ACTION staff with follow up steps. Looking forward to working with you!

** Please note : Sign your name on your Therapy Portal forms and do not only type your name.

Summer Program Registration

Student Information