RFK Camper Application

Would you like to learn more about our mentor program?

YesNo

Camper's Legal Name*

First NameLast Name

Preferred name for name tag*

Please upload a current photo of the child (if unable to upload, please send to FTCCentralCoast@gmail.com)

Browse Files

Case Number

Gender*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birthdate*

Date

Age as of 06/09/2025*

Emotional Age*

School*

Grade*

This child is *

This child has moved in foster placement how many times?*

This child is living with *

Describe Other

Name(s) of person(s) the child is living with:

Has this child participated in previous Royal Family KIDS Camps?

YesNo

What year(s) and location(s)

T Shirt Size*

Primary Caregiver's Name*

First NameLast Name

Primary Caregiver's Phone*

Area CodePhone Number

Secondary Phone for Caregiver

Area CodePhone Number

Primary Caregiver's email. This will be used to communicate important details for camp attendance (repeat in second box to confirm)*

Confirmation Emailexample@example.com

Alternate Contact (not the Case Worker and someone not living in your home)*

First NameLast Name

Alternate Contact Phone Number*

Area CodePhone Number

Social Services Case Worker*

First NameLast Name

Placement Agency Name*

Case Worker's Phone Number*

Area CodePhone Number

Case Worker's Email*

example@example.com

Explain any unusual family circumstances that may make camp especially important for the child: (ex recent crisis, being moved in foster placement, severe economic needs, etc.)

Who (other than caseworker and listed primary caretaker) is an authorized adult that may pick this child up after camp on June 13? **Government ID required** *

First NameLast Name

Authorized Adult #1 Phone Number*

Area CodePhone Number

SECOND authorized adult. **Government ID required**

First NameLast Name

Authorized Adult #2 Phone Number

Area CodePhone Number

How many siblings of this camper are applying for RFKC Santa Cruz?*

1. Name of sibling*

First NameLast Name

1.This sibling is a*

2. Name of sibling*

First NameLast Name

2.This sibling is a*

3. Name of sibling*

First NameLast Name

3.This sibling is a*

Check all that apply*

For items above that are checked, please provide suggestions of effective ways to prevent or resolve behavior*

Please describe the eating disorder*

Suggestions of effective ways to reinforce positive behavior

Please tell us what this child's interests, passions, loves, etc. are so our staff can make camp even more special! (i.e. Loves sports, interested in horses...whatever!)*

This helps us customize Birthday Party gifts to this camper!

What is this camper's favorite color?

This helps us customize Birthday Party gifts to this camper!

Are there any main characters, sports teams, or themes this camper is interested in? (i.e. Disney princesses, Among Us, Minecraft, Golden State Warriors, etc)

This helps us customize Birthday Party gifts to this camper!

Please tell us some strengths and positives about this camper (They are kind, they watch out for others, they are creative, etc)*

We do a lot of fun things at camp like using temporary glitters, tattoos, spray on hair color, and nail polish. Does your camper have permission to participate in all of these activities?*

YesNo

Does this child have any non-dietary allergies?*

YesNo

Allergies and Reactions*

Does this child have any illnesses/medical complications?*

YesNo

Illnesses/medical complications*

Does this child have any disabilities or limitations?*

YesNo

Disabilities or Limitations*

Does this child use Hearing Aids?*

YesNo

Other Medical Issues*

Please provide more detail on Medical Issues*

Any Sensory Processing Issues?*

YesNo

Please explain*

Are there any activities that should be encouraged?*

YesNo

What specific activities?*

Are there any activities that should be restricted?*

YesNo

What specific activities and why?*

Are immunizations current? Please note that all immunizations must be current in order to attend camp*

YesNo

Attach current immunization record (if unable to upload, please send to FTCCentralCoast@gmail.com)

Browse Files

Any dietary restrictions or allergies?*

YesNo

Please list ALL dietary restrictions and allergies*

How many medicatons does this child take?*

1. Medication*

1. Dosage*

1. How to Give*

1. Times to Give*

2. Medication*

2. Dosage*

2. How to Give*

2. Times to Give*

3. Medication*

3. Dosage*

3. How to Give*

3. Times to Give*

4. Medication*

4. Dosage*

4. How to Give*

4. Times to Give*

Health Care Provider's Name*

Health Care Provider Phone Number*

Area CodePhone Number

I understand that it is my responsibility as caregiver to make sure that all instructions are clear and that the necessary dosage is adequately supplied for the duration of camp. I hereby authorize RFK's nurse to administer the above medication from June 9 - 13, 2025. Medications must come in the original prescription bottle with the correct dosage on the label. Be prepared to review the medications and prescriptions with the camp nurses

Medical Release Form

This health history is correct so far as I know, and the above named minor has permission to engage in all prescribed program activities, except as noted. I do hereby authorize the directors of Royal Family KIDS Camp Santa Cruz or such substitute as they may designate as agent for the undersigned to consent to an x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care for the above minor which is deemed advisable by and to be rendered under the general or special supervision of any physician or surgeon, licensed under the provision of the Medicine Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, camp or elsewhere. This authorization will remain effective while the above minor is en route to and from or involved or participating in any camp program, unless revoked in writing by the undersigned and delivered to the Director of Royal Family KIDS Camp Santa Cruz as legal through Christian Life Center.

I agree to the above statement and understand that if I choose "no" my child will not be able to attend camp and this application become void.*

YesNo

Child's Medicaid or other insurance Number*

Medical Verification Contact Name*

First NameLast Name

Medical Verification Phone Number*

Area CodePhone Number

Do NOT administer these applications to this child

Detailed instructions regarding above list, if any*

Is there anything else we should know about this child?

Parent, Legal Guardian, or Social Worker Signature (Sign with finger on touch pad or with your mouse)*

Name of person signing above*

First NameLast Name

Relation to camper*

CAMPER APPLICATION WINDOW HAS NOW CLOSED. ANY APPLICATIONS SUBMITTED FROM 4/7/25-5/30/25 WILL BE PUT ON A WAITLIST

Sponsored by Christian Life Center

2025 Camp Week: June 9-13

Camper Application

Any application not fully completed will be returned and the child will be at risk of not being accepted to camp.

Mentor Club!

Camper's Details

Authorized to pick up Camper on Friday, June 13th

Siblings

Camper's Emotional and Behavioral History

Camper's Health History

Prescription Medication - all medication sent to camp must be in original container with the pharmacy label on it

Permission to administer over-the counter medications

Please check which of the medications listed below should NOT be administered by Royal Family KIDS Camp nurses: