2022 RFK Camper Application

Royal Family KIDS Camper Application 2022

The available Camp Dates are June 13-17 or June 20-24. Please allow 10 minutes to complete this form, it must be completed all at once. Do not close your browser until the "thank you" page appears after you hit submit. If it does not progress to a new page, ensure you have completed all required (*) fields
Please upload a recent picture of your child:

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OR Take Photo
Name of Child: *

First Name Middle Name Last Name
Preferred Name/Nickname:
Has the child attended Royal Family KIDS camp before? *
How did you hear of Royal Family Kids?
Camp Date Request *

June 13-17 June 20-24 Either
Explanation for camp date request:
Gender *
Child's Age At Camp: *
Child's Birth Date *

Month Day Year
Child's Emotional Age: *
May be different than child's chronological age
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Name of school child attends:
The child is living with: *

Foster Parent Group Home Relative
Name of person child is living with (Primary Contact): *

First Name Last Name
Phone number of person(s) child is living with: *

Area Code Phone Number
Names, relationships phone #s of other responsible adults (allowed for emergency contact or pickup)
(others in case emergency contact needs to be made and primary is unavailable)
Email of Primary Caregiver *

Confirmation Email example@example.com
Is your child assigned to a social worker? *
Social Worker's Name: *

First Name Last Name
Social Worker's Agency: *
Social Worker's Daytime Phone Number: *

Area Code Phone Number
Moved in foster care how many times? *
ex: 5
Explain any unusual family circumstances that make camp especially important for the child: *
Please list any emotional/behavioral issues that have been observed in the child. Describe triggers, frequency, known healthy coping mechanisms and anything else you would like to mention.
Examples: Aggressiveness, Bedwetting, Biting, Eating Disorders, Learning Disabilities, Night Terrors, Running Away, Sexual Acting Out, Stealing, Lying, Withdraws etc.
Swimming Ability: *
Reading Level: *
Please enter a numeric value corresponding to the grade level

Camper Preferences: *

	Explanation
Child's Favorite Characters
Child's Favorite Color
Child's Favorite Activity/Hobby

Camper's T-shirt Size: *
Medical
Known Allergies *

Yes No
Allergies: *
Any specific activities to be restricted?
Vaccinations up to date for school? *

Yes
If possible, please upload a photo/scan of child's vaccination record.

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Is your child taking prescribed medications? *

Yes No
I understand that it is my responsibility as caregiver to make sure that all instructions are clear, the necessary dosage is adequately supplied for the duration of camp, and all medication arrives in the original packaging. I hereby authorize RFK's Camp nurse to administer the above medication during camp. *

Clear
1) Please list any health conditions or comments. If possible, include dates, severity, complications, residual impairments, known helpful treatments. 2) List any devices regularly used as well (hearing airs, contact lenses, glasses) 3) List purpose for medications.
Doctor's Name: *

First Name Last Name
Doctor's Office Name or Location
Doctor's Phone Number: *

Area Code Phone Number
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. The undersigned do hereby authorize the directors of 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 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, hospital, camp or elsewhere. Pertinent protected health information of the camper may be released to the nurse for purposes of evaluation and treatment of the camper during the week of camp. 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 Director of Royal Family as legal guardian/social worker/other. I give my permission for the above mentioned minor to attend Royal Family KIDS Camp. *

Clear
Print Name: *
Above signer's relationship to child: *
Child's Medicaid ID#
Child's alternate insurance provider:
Child's alternate insurance ID#:
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 RFK Camp Registered Nurse to use her best judgment as situations arise, and if in doubt, he/she can call for verification.

Please check Yes or No for the medications listed below. This form must be completely filled out by the primary caregiver who signs below, or camper may not attend camp.
Over the counter products allowed: Sunblock, Insect Repellent, Lip Balm, Rash Ointment, Tylenol, Antiseptic Ointment, Band-aids, Anti-Itch Cream, Wound Cleanser, Cough Syrup, Cough Drops, Decongestant, Antihistamine, Electrolyte Replacement. *

Yes
Parent or Legal Guardian's Signature *

Clear
Print Name: *
PLEASE NO ELECTRONIC DEVICES, CAREMAS, MONEY OR FOOD. THESE ITEMS ARE NOT NEEDED AT CAMP.
Should be Empty:

Royal Family KIDS Camper Application 2022

Medical