RFKC NEW RFK Camper Application 2021

2021 Royal Family Kids Camp Camper Registration Form

A Camp for Foster Children 7-11 Years Old
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.
Camper Information
Child's Name *

First Name Last Name
Child's Preferred Name
DHS Case # *
Sex *

Male Female
Birth Date *

Month Day Year
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 *
Camper History
Has the child attended Royal Family Kids Camp in the past? *

Yes No
Which Royal Family KIDS Camp location? *
Date entered into foster care: *

Month Day Year
Date
Date entered into current placement: *

Month Day Year
Date
How many placements has the child experienced? *
Are the birth parents still involved with the child? *

Yes No
Are any siblings 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Withdrawn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) *
Camper Medical Information
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

Cancel of
Is the child taking any prescription medications? *

Yes No

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.
Sun Block Insect Repellant Lip Balm Antiseptic Ointment Antihistamine Tylenol Band-Aids Anti-Itch Cream Rash Ointment Cough Drops
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.

COVID-19 Release: I understand and agree that if my camper is showing signs of COVID-19 I will keep them home. I understand if my camper shows
signs of COVID-19 while at Royal Family KIDS Camp Novi, they will be quarantined and a guardian will be required to pick the camper up immediately.
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: *
Foster Parent/Legal Guardian Information
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 *
Alternate contact phone number *

Area Code Phone Number
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
Royal Family KIDS Mentoring Club Program
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:
Print your name *

First Name Last Name
Signature *

Clear
THANK YOU!
Comments or Questions
Should be Empty:

2021 Royal Family Kids Camp Camper Registration Form

Camper Information

Camper History

Camper Medical Information

Foster Parent/Legal Guardian Information

Royal Family KIDS Mentoring Club Program

THANK YOU!