RFKC NEW RFK Camper Application 2021

Sponsored by Brightmoor Christian Church 40800 W 13 Mile Rd Novi MI 48377

Instructions: This form must be completely filled out without closing the active session/tab. * indicates a required field. If the page will not allow you to submit, then check for a missing entry of a required field. Your application will not be processed until all information has been received.

Please mark your calendar with these important dates:

CAMP is July 26 - July 30, 2021

If you have any questions throughout this application, please send an email to campers@novirfkids.org.

Child's Name *

First Name Last Name

Child's Preferred Name

DHS Case # *

Sex *

Male Female

Birth Date *

Date

Age *

Cognitive Age *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

School *

Grade Entering in Fall 2021 *

Reading Level

T-Shirt Size *

Child Small Adult Small Child Medium Adult Medium Child Large Adult Large

Shoe Size *

Has the child attended Royal Family Kids Camp in the past? *

Yes No

Which Royal Family KIDS Camp location? *

Date entered into foster care: *

Date

Date entered into current placement: *

Date

Is the child legally adopted? *

Yes No

How many placements has the child experienced? *

Are the birth parents still involved with the child? *

Yes No

Are any siblings currently in foster care? *

Yes No

What are the siblings names and ages?

Are there any other foster children placed in the same home that may attend Royal Family Kids Camp?

Yes No

What are their names and ages?

Please describe any changes to routine, behaviors, or environment that the child has experienced due to the COVID-19 pandemic:

Please share some background information that would be beneficial to the child's counselor at Camp:

Has your child been in your care for less than 3 months and/or is your child placed in a residential facility? *

Yes No

Camper's Emotional/Behavioral History *

Often

Sometimes

Not at all

Aggressiveness

Bedwetting

Biting

Eating Disorder

Hyperactive

Overwhelmed in Groups

Lying

NIght Terrors

Nighmares

Runs Away

Sexually Acting Out

Steals

Tantrums

Withdrawn

Additional explanations for the above responses

What are some typical warning signs that your child is becoming escalated? (If none type NA) *

What are some typical triggers that will escalate your child? (If none type NA) *

What are some coping skills or strategies that you or your child have used when he or she is escalated? (If none type NA) *

Does your child have any known allergies, illnesses, disabilities, or physical limitations *

Yes No

Indicate any known allergies, illnesses, disabilities, or physical limitations *

Is this a sexual abuse case? *

Yes No

Immunization History: Please email a copy immunization record to campers@novirfkids.org or upload below:

Immunization record **This can be emailed at a later date if not currently available:

Browse Files

Is the child taking any prescription medications? *

Yes No

Please fill in the following: *

Name

Dosage

Time

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Physician's Name *

First Name Last Name

Physician's Phone Number

Area Code Phone Number

Child's insurance provider *

Child's insurance number *

IMPORTANT NOTE: MEDICATIONS MUST BE IN ORIGINAL PERSCRIPTION BOTTLES FROM PRESCRIBING PHYSICIAN. Campers must be accompanied by proper dosages for the duration of the camp week.

I give the the Royal Family Kids camp nurse permission to administer the following over the counter products according to manufacturer's instructions, or as otherwise specified, if needed. Please check any that you do not wish to be administered. The Royal Family Kids camp registered nurse will use their best judgement as situations arise, and if in doubt, he/she will call for verification.

I hereby authorize Royal Family Kids camp nurse(s) to administer medication from 07-26-2021 to 07-30-2021

Print your name *

First Name Last Name

Signature *

Clear

Medical Release: 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. The undersigned do hereby authorize the directors of Novi Royal Family Kids camp 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, liscensed under the provision of the Medicine Practice Act or any dentist liscensed under the Dental 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 minor is in route to and from or involved or participating in any camp program, unless revoked in writing by the undersigned and delivered to the directors of Novi Royal Family Kids camp as legal guardian/foster care case manger/other.

I give my permission for the following child to attend Royal Family Kids camp and be treated medically if needed *

First Name Last Name

Print your name *

First Name Last Name

Signature *

Clear

My relationship to the child is: *

1. I acknowledge that For the Children (RFK) Novi is taking reasonable precautions to mitigate the risks associated with COVID-19. I understand that such risks cannot be eliminated entirely, as COVID-19 may spread through multiple pathways. I also understand that although reasonable precautions are taken, my child may become infected with COVID-19. I also understand the health risks associated with COVID-19 infection including potential exposure to others including family members.

2. I expressly agree to accept and assume all risks associated with COVID-19 related to my child’s participation in the Program. I have elected to allow my child to participate in the Program despite the risks of COVID-19. I recognize that this decision is purely voluntary and that I have the right to discontinue my child’s participation in the Program at any time.

3. I understand that For the Children (RFK) Novi may modify and/or cancel a Program as a result of COVID-19 issues or may be directed to modify and/or cancel a Program by government authorities.

4. I understand that For the Children (RFK) Novi reserves the right to segregate, remove, quarantine, and/or dismiss my child for COVID-19 reasons and/or take all reasonable steps to maintain and protect the health and welfare of my child and other Campers, staff, and volunteers.

5. I acknowledge that I will remain solely responsible for my other costs incurred in connection with my child’s participation in the Program, including transportation and incidental costs, even in the event that For the Children (RFK) Novi is required to or deems it necessary to cancel or modify the Program, or For the Children (RFK) Novi dismisses my child from the Program.

6. I represent to For the Children (RFK) Novi or will represent to For the Children (RFK) Novi prior to presenting my child for participation in the Program that, to my knowledge, my child (a) has not been diagnosed with COVID-19, (b) has not been exposed to a person presumed or confirmed to have COVID-19 within the fourteen days preceding my child’s participation in the Program, and (c) is free of any signs and symptoms of COVID-19 (which may include a fever, a dry cough, excessive fatigue, shortness of breath). I represent I will notify For the Children (RFK) Novi of any change in my child’s medical status that occurs prior to the start date of the term for which he/she is registered.

7. I HEREBY VOLUNTARILY RELEASE, WAIVE, AND FOREVER DISCHARGE ANY AND ALL CLAIMS AGAINST For the Children (RFK) Novi, ITS BOARD OF DIRECTORS, OFFICERS, EMPLOYEES, VOLUNTEERS, AGENTS AND ALL OTHER PERSONS OR ENTITIES AFFILIATED WITH For the Children (RFK) Novi OR ACTING ON ITS BEHALF THAT RELATE IN ANY WAY TO COVID-19, INCLUDING BUT NOT LIMITED TO ANY CLAIM ARISING FROM OR RELATING TO MY CHILD’S EXPOSURE TO, INFECTION WITH, OR OTHER HARM RELATED TO COVID-19 WHILE PARTICIPATING IN THE PROGRAM AND/OR FOLLOWING PARTICIPATION IN THE PROGRAM, AND ALSO INCLUDING HARM RELATED TO MY CHILD’S SPREAD OF COVID-19 TO ME AND/OR OTHERS INCLUDING FAMILY MEMBERS. I FURTHER AGREE TO REIMBURSE XYZ CAMP FOR ATTORNEY FEES INCURRED RELATED TO ENFORCING THIS WAIVER PROVISION.

8. I agree to indemnify and hold harmless For the Children (RFK) Novi from and against any liabilities, claims, causes of action, suits, losses, fines, judgments, settlement, and expenses (including reasonable attorney fees) which may be incurred by For the Children (RFK) Novi as a consequence of my child’s exposure to COVID-19 resulting in the illness or infection of a third-party.

9. The provisions of this Addendum are severable, and if any provision of this Addendum is held to be invalid or unenforceable, the remaining provisions will remain in full force and effect.

10. This Addendum is intended to supplement the 2020 Camper Application previously executed and is in addition to the terms stated therein, which shall remain in full force and effect.

By signing this ADDENDUM, which includes an ASSUMPTION OF RISK, RELEASE, WAIVER OF LIABILITY, AND INDEMNIFICATION AGREEMENT RELATED TO COVID-19, I expressly state that I have had sufficient opportunity to read it in its entirety. I further certify that I have read and understood it, and I agree to be bound by its terms.

Print your name *

First Name Last Name

Signature *

Clear

My relationship to the child is: *

Name of foster parent/legal guardian child is living with *

First Name Last Name

Foster parent/legal guardian phone number *

Area Code Phone Number

Foster parent/legal guardian e-mail

example@example.com

Best way to contact foster parent/legal gaurdian? *

Email Phone Call Text Message

Alternate contact person *

First Name Last Name

Relation of alternate contact to child *

Email of alternate contact to child

example@example.com

Alternate contact phone number *

Area Code Phone Number

Is there a Foster Case Specialist working with the camper? *

Yes No

Foster Case Specialist *

First Name Last Name

Foster Care Specialist Day Phone *

Area Code Phone Number

Foster Care Specialist Emergency Phone *

Area Code Phone Number

Foster Care Specialist E-mail *

example@example.com

Do you require permission from multiple guardians? *

Yes No

How many additional signatures are needed? *

Name of alternate guardian #1 *

First Name Last Name

Relation of alternate contact #1 to child *

Does guardian #1 have access to email? *

Yes No

Alternate guardian #1 e-mail *

example@example.com

Name of alternate guardian #2 *

First Name Last Name

Relation of alternate contact #2 to child *

Does guardian #2 have access to email? *

Yes No

Alternate guardian #2 e-mail *

example@example.com

Name of alternate guardian #3 *

First Name Last Name

Relation of alternate contact #3 to child *

Does guardian #3 have access to email? *

Yes No

Alternate guardian #3 e-mail *

example@example.com

Name of alternate guardian #4 *

First Name Last Name

Relation of alternate contact #4 to child *

Does guardian #4 have access to email? *

Yes No

Alternate guardian #4 e-mail *

example@example.com

Kids who have attended Royal Family KIDS Camp can apply for Royal Family KIDS Club. RFK Club will provide fun times with their own matched adult mentor (trained and cleared) for 4 hours a month plus once-a-month Club time events during the school year. Approved Mentors can help with transportation and there is no fee for participation. Club participation includes a backpack, club shirt and other Club materials.

Are you interested in your child attending Royal Family KIDS Club next school year? *

Yes No

LIMITED ENROLLMENT AGREEMENT FOR CAREGIVERS: By selecting yes in the question above I understand that the number of children matched and admitted is limited by the number of mentors available, and that age and geography are also limiting factors. As part of the matching process, and I give permission for Camp staff to share my child’s Camper Application information (including social worker contact information) with Club leaders in order to better match my child to a qualified mentor.

If a mentor is available, you will be contacted by the Club Mentoring Director later in the summer to discuss the match with a qualified mentor for your child during the next school year.

By signing below, I certify all information in this application is true and correct to the best of my knowledge:

2021 Royal Family Kids Camp Camper Registration Form

Camper Information

Camper History

Camper Medical Information

COVID-19 ADDENDUM TO 2020 PARENT / LEGAL GUARDIAN RELEASE FOR CAMP & CAMPERS

Foster Parent/Legal Guardian Information

Royal Family KIDS Mentoring Club Program

THANK YOU!