MYC Camper Registration

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Camp is Monday through Friday, July 27th to July 31st. The drop-off and pick-up location will be sent to the contact e-mail provided. The child will leave on Monday morning and return Friday afternoon. Our camp is in the beautiful state of Missouri. Swimming, exploring, fishing, rock climbing, and zip lining are just a few of the activities they will be able to participate in. Bible stories, music and a variety of non-competitive sports will round out a program emphasizing wholesome exercise and the building of positive memories. The opportunity to develop good attitudes toward peers, to learn about the outdoors, will be present everywhere for them. They will have life long memories!

All of our volunteers have current background checks and attend training. No child is ever alone with an adult. There is always at least TWO adults with the kids, so the camper will have individualized attention.

Mission YOUTH Camp is 100% volunteer run and donation based. We are dedicated to making moments matter!
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Child's Name* This field is required.Please make sure spelling is correct
First Name
Last Name
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Preferred First Name* This field is required.Please make sure spelling is correct
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Please upload a current picture of the child.* This field is required.
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Gender* This field is required.
Male
Female
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Birthdate* This field is required.Must be at least 6 years old on July 1st and not older than 12 during camp.
Month
Day
Year
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Age during camp* This field is required.Must be at least 6 years old on July 1st and not older than 12 during camp.
6 years old
7 years old
8 years old
9 years old
10 years old
11 years old
12 years old
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Is this child attending or has attended a different Royal Family Kids camp or TRAC this summer?* This field is required.We give priority to kids who are not attending or has not attended an RFK camp or TRAC.
YES (attending a different RFK camp or TRAC)NO (NOT attending a different RFK camp or TRAC)
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Has this child attended RFK #313 of Johnson County before?* This field is required.
Yes, the child has attended the Johnson county RFK #313 camp before
No, not a returning RFK Camper
I don't know if child has been to RFK Camp before
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If child is a returning Royal Family KIDS camper and had a DIFFERENT NAME, please let us know.
First Name
Last Name
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Child's T-Shirt Size (camp shirts run small)* This field is required.
Child Small
Child Medium
Child Large
Child XL
Adult Small
Other
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Emotional Age * This field is required.Does this child act older or younger than his or her current age?
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What grade will the child be entering in the fall?* This field is required.
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Reading grade level* This field is required.
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Are siblings applying to Mission YOUTH Camp?* This field is required.A SEPARATE registration will need to be completed for EACH child.
YESNO
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If a sibling of this child is applying to camp, please tell us their nameA SEPARATE registration will need to be completed for EACH child.
First Name
Last Name
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This sibling is a...
Biological Sibling
Foster Sibling
Group home sibling
Sibling in Adoptive Family
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If 2nd sibling is applying to camp, please tell us their nameA SEPARATE registration will need to be completed for EACH child.
First Name
Last Name
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2nd sibling is a...
Biological Sibling
Foster Sibling
Group home sibling
Sibling in Adoptive Family
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If 3rd sibling is applying to camp, please tell us their nameA SEPARATE registration will need to be completed for EACH child.
First Name
Last Name
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3rd sibling is a...
Biological Sibling
Foster Sibling
Group home sibling
Sibling in Adoptive Family
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If 4th sibling is applying to camp, please tell us their nameA SEPARATE registration will need to be completed for EACH child.
First Name
Last Name
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4th sibling is a...
Biological Sibling
Foster Sibling
Group home sibling
Sibling in Adoptive Family
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The child is living in a* This field is required.
Foster Home
Group Home
Adoptive Parent(s) Home
Relatives Home
Biological Parent(s) Home
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At time of camp, how long will this child have been living in current home?* This field is required.
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Total number foster or residential placements for child including current home* This field is required.
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Home Mailing Address * This field is required.for camp correspondence
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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What county does the child live in?* This field is required.
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Contact Name* This field is required.This person will be the one we notify for acceptance/denial and correspond with concerning camp & emergencies.
First Name
Last Name
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Relationship to Child* This field is required.
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Contact Cell Phone Number* This field is required.This person will also receive text updates about camp & emergencies.
Area Code
Phone Number
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Contact Email Address* This field is required.This person will receive the email auto-reply and future email correspondence regarding child.
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Legal Guardian * This field is required.
First Name
Last Name
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Legal Guardian Relationship to Child* This field is required.
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Legal Guardian Cell Phone Number* This field is required.
Area Code
Phone Number
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Legal Guardian Email Address* This field is required.
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Who is an authorized adult that may pick this child up after camp? IF THIS CHANGES YOU MUST CALL TO NOTIFY US!! **ID required*** This field is required.
First Name
Last Name
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Cell Number for Authorized Adult * This field is required.
Area Code
Phone Number
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SECOND authorized adult. **ID required*** This field is required.
First Name
Last Name
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Cell Number For Second Authorized Adult* This field is required.
Area Code
Phone Number
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Does the child have a current Caseworker?* This field is required.
Yes
No
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Caseworker Name* This field is required.
First Name
Last Name
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Caseworker Email* This field is required.
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Caseworker Cell Phone* This field is required.
Area Code
Phone Number
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Why would this child's attendance at Mission YOUTH Camp important? Why would you like him or her attend camp?* This field is required.
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How often does this child wet the bed at night?* This field is required.
Never wets the bed
Rarely wets the bed
Frequently wets the bed
Wets the bed every night
Do not know about bed wetting
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If child does wet the bed, please explain (i.e. wears pull-ups, don't drink liquids after certain time, just need to be aware, etc.)
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Does this child display aggressive behavior?* This field is required.
Never aggressive
Rarely aggressive
Frequently aggressive
Always Aggressive
Do not know if child is aggressive
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Please explain aggressive behavior. (What may trigger aggressive behavior or to whom child is aggressive.)
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Does the child deal with any of the following eating disorders or issues around food?* This field is required.
No Eating Disorders
Anorexia
Bulimia
Overeating/Gorging
Hoarding or Stealing Food
Do Not Know Of Any Eating Disorders
Other
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If this child does have an eating disorder - or has other issues around food we should know about - please explain.
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How would you describe this child's demeanor?* This field is required.
Very calm
Somewhat hyperactive
Frequently hyperactive
Always hyperactive
Do not know about hyperactivity
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Please let us know if any of the following learning difficulties exist for this child.* This field is required.
No learning difficulties
Hearing impairment
Vision impairment (that would affect time at camp)
Reading difficulties
Do not know about learning difficulties
Other
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How often does this child lie?* This field is required.
Never lies
Rarely lies
Frequently lies
Always lies
Can not tell lies from truth
Do not know if this child has a habit of lying
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Please let us know how often this child has nightmares.* This field is required.
No nightmares
Rarely has nightmares
Frequently has nightmares
Do not yet know about nightmares
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Please let us know how to calm this child or prevent nightmares.
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Please let us know how often this child runs away from a situation or from home.* This field is required.
Never runs away
Rarely runs away
Frequently runs away
Always runs away
Do not yet know if child runs away
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Please let us know if - or how - this child may act out sexually.* This field is required.
Does not act out sexually
Touches self
Touches other children
Flirts or pays inappropriate attention to adults
Do not know if sexually acts out
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If this child does act out sexually, please explain.(We will use this information to pay attention to certain behaviors or understand what situations may trigger acting out and how we can help re-direct.)
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How often does this child steal things?* This field is required.
Never steals
Rarely steals
Frequently steals
Know of stealing in the past, but not currently
Do not know about stealing yet
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How often does this child have tantrums or anger issues?* This field is required.
Does not have tantrums or anger issues
Rarely has tantrums or anger issues
Frequently has tantrums or anger issues
Do not know about tantrums or anger yet.
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If this child does have tantrums or anger issues that are beyond normal childhood frustrations, please explain so we know how to redirect or prevent outbursts.(Please let us know how we can calm this child or redirect the situation to prevent tantrums. We want your child to have an amazing week at camp, so any information we can have to help calm this child would be very helpful.)
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How often does this child withdraw?* This field is required.
Never withdrawn
Rarely withdrawn
Frequently withdrawn
Do not know about how often child withdraws yet
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** Please tell us about this child's history or story. What situations may have been challenging for this child before living in your home? What circumstances is this child dealing with?* This field is required.We expect and look for great things in each and every child. We also know that many of these children have had difficulties in their past which have shaped their present reality. Please give some information about his or her past so we can better understand this child.
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If this child attended Royal Family KIDS Camp #313 in the past, what did he or she like about it?* This field is required.We expect and look for great things in each and every child. We also know that many of these children have had difficulties in their past which have shaped their present reality. Please give some information about his or her past so we can better understand this child.
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List ALL known ALLERGIES to food, plants, medications, animals, etc. (If none, put N/A)* This field is required.
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This child's swimming ability is...* This field is required.life jackets are provided & a CPR certified volunteer will be at the pool
Excellent Swimming Ability
Good Swimming Ability
Poor Swimming Ability
Do Not Know Swimming Ability
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Illnesses and Medical Complications Past or Present* This field is required.
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Disabilities/Limitations Past or Present* This field is required.
Huge
Large
Normal
Small
Ok
Ok
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What, if any, specific activities should be DISCOURAGED for medical reasons while at camp?
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PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATIONS* This field is required.I hereby give the Mission YOUTH Camp Nurse permission to administer the following products according to manufacturer’s instructions, or as otherwise specified. I trust the MYC Nurse to use their best judgment as situations arise, and if in doubt, they can call for verification.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Sunblock/Sunscreen
Insect Repellent
Chapstick
Band-aids
Children's Tylonel
Anti-Itch Cream/Rash Ointment
Triple Antibiotic Ointment
Hydrogen Peroxide
Cough Syrup/Decongestant
Cough Drops
Allergy Relief/Antihistamine
Sunblock/Sunscreen
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
1 of 11
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Is the child on any Prescription and/or Over the Counter Medications?* This field is required.List each one separately
Yes
No
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Prescription or Over-the-Counter Medication #1List each one separately
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Prescription Medication 1: Reason for taking, DOSAGE, and Time(s) of Day to Administer
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How long as child been taking Medication #1? (Be specific.)
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Prescription or Over-the-Counter Medication #2List each one separately
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Medication 2: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
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How long has child been taking Medication #2? (Be specific.)
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Prescription or Over-the-Counter Medication #3List each one separately
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Medication 3: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
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How long as child been taking Medication #3? (Be specific.)
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Prescription or Over-the-Counter Medication #4List each one separately
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Medication #4: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
84
How long as child been taking Medication #4? (Be specific.)
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Prescription or Over-the-Counter Medication #5List each one separately
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Medication #5: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
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How long has child been taking Medication #5? (Be specific.)
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Additional information we need to know about the above prescription drugs, vitamins, or over-the-counter medications sent to camp - or - additional medications, if any. For example any side effects?
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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 Mission YOUTH Camp nurse to administer the above medication during the week of camp.* This field is required.
Yes
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Insurance provider* This field is required.
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Insurance number* This field is required.
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Enter Primary Doctor's Information* This field is required.
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MEDICAL RELEASE FORM: * This field is required.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 Mission YOUTH 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 and surgeon, licensed under the provision of the Medicine Practice Act or any dentist licensed 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 and to be released from said place to a MYC representative if guardian or appointee is unavailable. This authorization will remain effective while the above minor is enroute to and from or involved or participating in any camp program, unless revoked in writing by the undersigned and delivered to the Directors of Mission YOUTH Camp as legal guardian/social worker/other. I give my permission for the above named child to attend Mission YOUTH Camp sponsored through Mt Home Community Church.
I understand and agree to the medical release. Signature below.
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COMMUNICABLE DISEASES RELEASE FOR CAMP & CAMPERS: * This field is required.I hereby agree as follows: 1. I acknowledge that Mission YOUTH Camp (MYC) is taking reasonable precautions to mitigate the risks associated with communicable diseases i.e. covid, flu etc. I understand that such risks cannot be eliminated entirely, as a communicable disease may spread through multiple pathways. I also understand that although reasonable precautions are taken, infection may be possible. I also understand the health risks associated with communicable disease infections including potential exposure to others including family members. 2. I expressly agree to accept and assume all risks associated with communicable diseases related to my participation in the Program. I have elected to participate in the Program despite the risks of communicable diseases. I recognize that this decision is purely voluntary. 3. I understand that Mission YOUTH Camp may modify and/or cancel a Program as a result of communicable disease issues or may be directed to modify and/or cancel a Program by government authorities. 4. I understand that MYC reserves the right to segregate, remove, quarantine, and/or dismiss someone for communicable disease reasons and/or take all reasonable steps to maintain and protect the health and welfare of the children and other Campers, staff, and volunteers. 5. I will remain solely responsible for my costs incurred in connection with participation in the Program, including transportation and incidental costs, even in the event that Mission YOUTH Camp is required to or deems it necessary to cancel or modify the Program, or MYC dismisses the Program. 6. I represent to MYC or will represent to MYC prior to participation in the Program that, to my knowledge, I have not been diagnosed with a communicable disease, (b) have not been exposed to a person presumed or confirmed to have a communicable disease within a determined number of days preceding participation in the Program, and(c) is free of any signs and symptoms of a communicable disease which may include a fever, a dry cough, excessive fatigue, shortness of breath, etc. I represent I will notify Mission YOUTH Camp of any change in my child’s medical status that occurs prior to the start. 7. I HEREBY VOLUNTARILY RELEASE, WAIVE, AND FOREVERDISCHARGE ANY AND ALL CLAIMS AGAINST MYC MINISTRIES, ITS BOARD OFDIRECTORS, OFFICERS, EMPLOYEES, VOLUNTEERS, AGENTS AND ALL OTHER PERSONS OR ENTITIES AFFILIATED WITH MISSION YOUTH CAMP OR ACTING ON ITS BEHALF THAT RELATE IN ANY WAY TO COMMUNICABLE DISEASES, INCLUDING BUT NOT LIMITED TO ANY CLAIM ARISING FROM OR RELATING EXPOSURE TO, INFECTION WITH, OR OTHER HARM RELATED TO COMMUNICABLE DISEASES WHILE PARTICIPATING IN THE PROGRAM AND/OR FOLLOWING PARTICIPATION IN THE PROGRAM, AND ALSO INCLUDING HARM RELATED TO THE SPREAD OF COMMUNICABLE DISEASES TO ME AND/OR OTHERS INCLUDING FAMILY MEMBERS. I FURTHER AGREE TO REIMBURSE MYC FOR ATTORNEY FEES INCURRED RELATED TO ENFORCING THIS WAIVER PROVISION. 8. I agree to indemnify and hold harmless Mission YOUTH Camp 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 MYC as a consequence of any exposure to communicable diseases 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 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 COMMUNICABLE DISEASES, 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.
I understand and agree to the COMMUNICABLE DISEASES waiver. Signature below.
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NO ELECTRONICS, CAMERAS, FOOD, OPEN TOED SHOES OR MONEY. * This field is required.The camper is NOT to bring any of these items.
I understand
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I agree not to share the location of camp!* This field is required.This is for the safety of the campers.
I will not share the camp location.
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Pictures and/or videos are NOT allowed during the closing ceremony at the church.* This field is required.I agree not to take pictures and/or videos at the church on Friday.
I agree not to take pictures and/or videos at the church during the closing ceremony at the church on Friday.
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I agree to let the directors know if the child can no longer attend camp as soon as possible.* This field is required.Each child fills a spot, if no longer able to attend we will try to fill the spot with a child that's on the wait list.
I agree
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Registration fee:* This field is required.The Non-Refundable fee is to help us reduce no shows and cancellations. Once the child is selected to come to camp we have several items that we personalize for them.
I understand there is a $20 Non-Refundable registration fee to be paid after submitting the camper registration form.
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Name of Person Filling Out This Application* This field is required.
First Name
Last Name
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Relationship to Child* This field is required.
102
Date* This field is required.
Date
Month
Day
Year
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Signature* This field is required.By signing I am agreeing to all the conditions and release any and all liability.
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