Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Referring Agency/School *Referrer Name *FirstLastReferrer Email *Referrer Phone Number *Child's Name *FirstLastChild's Date of Birth *Cooinda Retreats accepts referrals for children aged between 6 and 10 years old (based on the child's age at the time of the camp). Children cease to be eligible after their 11th birthday.Child's GenderChoose optionMaleFemaleOtherPrefer not to sayOptionalSupport NeedsPlease indicate areas where the child may need support, where 1 means little to no support, and 5 means ongoing, constant support.Managing Conflict Selected Value: 1Sensory Overload Selected Value: 1Self-Regulation Selected Value: 1Participation Selected Value: 1Personal Space Selected Value: 1Following Instructions Selected Value: 1Child's Background Information *Cooinda Retreats' programs are about providing a respite opportunity to young people who would otherwise miss out. Please provide some details of the child's background, home life, or school life, that will help us to assess their suitability for the program.Why is the GLOW Kids Camp the right experience for this child? What do you hope they will gain from attending? *Is there anything our volunteers should be mindful of when working with this child? Submit Referral
