Summer Recreation Application

Please complete the following application for Summer Recreation for the 2024 Summer season.

Before you begin, please be sure to have the following information ready:

  • Emergency contact information
  • Medicaid number and Tabs number
  • Other Insurance information (if applicable)
  • Diagnosis, allergies and medications
  • Care Manager contact information
  • Self Direction Support Broker and Fiscal Intermediary contact information (if applicable)
  • Participants interests and fears
  • Participants medical or dietary precautions, and adaptive equipment needs (including for transportation)
  • OPWDD Eligibility Letter (to upload)
  • Last two Life Plans (to upload)
  • Current Level of Care (to upload)
  • Service Authorization (if applicable) (to upload)
  • Self- Direction Budget (if applicable) (to upload)

If you have any questions, please contact