Summer Urban Program Youth Referral Form 2024

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

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 1. Open spots for specific age/grade/program will be directly shared with partners and families 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:

Select your first preference and information may be shared with multiple programs if spaces become available. Families will hear back from this program about their openings, deadlines, or referrals to other SUP programs or agencies:

Child/Student information

First Name

Last Name

Preferred name or Nickname (if applicable)

Gender identity

Gender: Write in my own

School information

School child will attend this fall:

Other School (if not BPS/CPS) please type full school name

Grade in school entering in Fall

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

Describe the students academic strengths and needs and how our staff can best support the student's growth in those areas (particularly English proficiency: reading, writing, listening, speaking, and how quickly the student learns new things)

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

Communication

Relations with Peers

Relations with Adults

Describe the students social and emotional strengths and needs and how the staff can best support the student's growth in those areas (how they interact with peers and teachers, motivation level, behavior plans/goals, etc.)

Optional:

Please follow up with me for more information if this student enrolls for the summer

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?

Family Referred to SUP Full Name 1	Family Referred to SUP Email 1
Family Referred to SUP Full Name 2 Family Referred to SUP Full Name 3	Family Referred to SUP Email 2 Family Referred to SUP Email 3

Thank you for taking the time to refer to SUP!

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

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