Summer Urban Program Youth Referral Form 2021

Thank you for your interest in PBHA's Summer Urban Program for your student(s)! If you have overall questions, contact Please read individual program descriptions, eligibility requirements and target population, and email each program's directors for any specific questions - all available at

About the Application Process:
  • This referral form expresses interest for a student to be contacted about a spot in a PBHA Summer Urban Program. The camp will contact you and the family with more information within 2 weeks. There will be additional documents for the family to submit in addition to this online form.
  • You may complete this form more than once for separate students.
  • First round deadline for referrals will be June 1st. Specific age/grade/program - open spots will be directly advertised after that date. 
Information needed to complete this referral form:
  • Contact information for child and parent/guardian(s).
  • School information for each child, including contact information for a point person at the referring school/agency. 
  • Knowledge of student's strengths and needs in language skills, social-emotional, behavioral, and individualized academic areas.

Please select a program:

Child/Student information

School information

Grade in school entering in Fall
Your Contact Information

Parent/Guardian of Child

(e.g. on my home phone from 7pm-10pm Monday through Thursday)

Student Referral Details

This information given may be used by a child's summer director and counselor to get to know how to build relationship and build skills with the student and family during orientation, goal-setting, grouping, and social and academic learning.
Academic Performance: Please indicate this student's performance in relation to grade level standards in the following subject areas:
Poor = Significantly below...; Needs Improvement = Somewhat below...; Satisfactory = at... ; Very Good = above...  grade level standards

Social-Emotional Support: Please indicate how often this student:


Relations with Peers

Relations with Adults

If you have other families in your network who you would like to receive an automated email regarding more information about the Summer Urban Program so they can follow up on their own, complete their names and emails below. Thank you!
Optional - More Referrals?

Thank you for taking the time to refer to SUP! 

(Once you confirm, it may take a few seconds to submit).