RFK Camper REGISTRATION FORM

Please submit application online or print and return to Camp Director.

Camp Directors:

Anna and Philip Beaty

(304)419-0546

forthechildrenputnam@gmail.com

forthechildrenputnam.com
Royal Family KIDS Camp

For kids who are in or have been in foster care/kinship care
Sponsored by: New Heights Church

1145 N Main Street, Milton, WV 25541
Camp Week: June 17-21, 2024
REGISTRATION FORM
Instructions: This form must be completely filled out. The information is vital to the health and well being of the child. Your application will be returned to you if it is not completely filled in.
Name*

Child's First NameChild's Last Name
Preferred Name*
Gender*
Child's Birthdate*
Ex: 08/02/2000
Age at time of camp (June 17th, 2024)*
Address
Street*
State*
City*
Zip*
School*
Grade*
Current Emotional Age*
Reading Level
The child is living with: (Check one)*

Foster ParentGroup HomeKinship Care/RelativeAdoptive Parent
Name(s) of person(s) which the child is living with*
Home Phone
Cell Phone*
Work Phone
Email Address to receive Camp Info.*
example@example.com
Emergency Contact*
Emergency Contact Phone*
Relationship to Child*
Social Worker
Day Phone Number
Moved in Foster Placement how many times?*
Explain any unusual family circumstances that make camp especially important for the child: (for example, recent crisis, being moved in foster placement, severe economic needs, etc.)*
CAMPERS EMOTIONAL/BEHAVIORAL HISTORY
Aggressiveness*

OftenSometimesNot at all
Bedwetting*

OftenSometimesNot at all
Biting*

OftenSometimesNot at all
Eating Disorders*

OftenSometimesNot at all
Hyperactive*

OftenSometimesNot at all
Learning and Disabilities*

OftenSometimesNot at all
Lying*

OftenSometimesNot at all
Night Terrors*

OftenSometimesNot at all
Nightmares*

OftenSometimesNot at all
Runs Away*

OftenSometimesNot at all
Sexual Acting Out*

OftenSometimesNot at all
Steals*

OftenSometimesNot at all
Tantrums*

OftenSometimesNot at all
Withdrawn*

OftenSometimesNot at all
Details from above:
Special Concerns:
CAMPER DETAILS:
Camper T-Shirt Size:*

Child SmallChild MediumChild LargeAdult SmallAdult MediumAdult Large
Pants/Shorts Size:*

4-66-88-1012-1416-18Adult SmallAdult MediumAdult Large
Shoe Size:*
This child's swimming ability is:*

PoorGoodI don't know
Learning Disability:*

YesNo
Has the child attended a Royal Family KIDS Camp before?*

YesNo
Yes, where?
HEALTH HISTORY
Indicate all known allergies, illness, disabilities, physical limitations, or medical complications.
Allergies*
Illnesses/Medical Complications*
Disabilities/Limitations*
Check any of the following which apply:

Leg or Arm BraceHearing AidsEating Disorder
Indicate date of illness, severity, complications, and any residual impairment. If it does not apply, leave blank or put N/A.
Respiratory Problems
Hypoglycemia
Musculoskeletal Allergies
Heart or Circulation
Dizzy Spells
Foot
Pulmonary Edema
Back
Seizure Disorders
Hay Fever
Anaphylactic Shock
Poison Oak
Balance Problems
Diabetes
Fainting
Insect Bites
Drug Allergy
Other
Details from above:
Any specific activities to be encouraged?*
Any specific activities to be restricted?*
IMMUNIZATION HISTORY:
Fill in dates of basic immunizations & most recent booster as best as you can or attach their immunization record.
DTP Series
Booster
Tetanus Booster
Polio OPV (Sabin)
Typhoid
German Measles (Rubella)
Mumps Vaccine (live)
Measles Vaccine (live)
Small Pox
Tuberculin (TB) Test
PRESCRIPTION MEDICATIONS: All medication sent to camp must be in original container with the pharmacy label.
Is your child taking any medications?*

YesNo
Yes, please fill in the following information.
Name of Medication:
Dosage:
Times:
Name of Medication:
Dosage:
Times:
Name of Medication:
Dosage:
Times:
Name of Medication:
Dosage:
Times:
Any additional medications, dosages, and times may be listed here
What is/are the medication (s) for?
Doctor's Name*
Phone*
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 RFKC’s nurse to administer the above medication from Mon., June 17, 2024 through Fri., June 21, 2024
Parent or Legal Guardian Signature*

Clear
Printed Name*
Date*

MonthDayYear
Date
MEDICAL RELEASE FORM:
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 RFKC’s nurse to administer the above medication from Mon., June 17, 2024 through Fri., June 21, 2024
Child's Name*
Authorized Signature/Legal Guardian*

Clear
Printed Name*
Date*

MonthDayYear
Date
Child's Medicaid #
Signature

Clear
Relationship to child:
Date
PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATIONS
I hereby give the Royal Family KIDS Camp Registered Nurse permission to administer the following products according to manufacturer’s instructions, or as otherwise specified. I trust the RFKC Registered Nurse to use her best judgment as situations arise, and if in doubt, he/she can call for verification.
Sunblock*

YesNo
Insect Repellant*

YesNo
Lip Balm*

YesNo
Rash Ointment*

YesNo
Tylenol*

YesNo
Antiseptic Ointment*

YesNo
Band-aids*

YesNo
Anti-Itch Cream*

YesNo
Hydrogen peroxide*

YesNo
Cough Syrup*

YesNo
Cough Drops*

YesNo
Decongestant*

YesNo
Antihistamine*

YesNo
Lipecac syrup*

YesNo
Any other medications that you would like the child to have access to, please list:
Parent or Legal Guardian Signature:*

Clear
Printed Name:*
Phone numbers:*
Person Authorized to pick up child*
PLEASE DO NOT SEND CAMERAS, PHONES, OR MONEY. THESE ITEMS ARE NOT NEEDED AT CAMP.
Please upload an image of the camper
Should be Empty:

Royal Family KIDS Camp

REGISTRATION FORM

CAMPERS EMOTIONAL/BEHAVIORAL HISTORY

HEALTH HISTORY

IMMUNIZATION HISTORY:

MEDICAL RELEASE FORM: