Camper Application

Camper Application

Please complete one application per child.
Royal Family Kids Camp, July 10-13, 2023

Drop off location: 915 S Cedar St., Colville, WA 99114 (campers will be transported to the camp location via bus)
Child's Name:

First NameLast Name
Child's preferred name (if different than above):
Child's gender:

FemaleMale
Please upload a recent photo of the child who will be attending camp:
Child's date of birth:

MonthDayYear
Date
Address where child currently resides:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of school the child attends:
Child's Grade:
The child is living with

Foster ParentsAdoptive ParentsRelativeGroup Home
Name of parent or legal guardian the child is living with:
Phone Number of legal guardian:
Please enter a valid phone number.
Email address of parent or legal guardian: (this email address will recieve a confirmation email)
example@example.com
Emergency Contact (include name, relationship, and phone number):
Social Workers Name (if none, leave blank):
Explain any unusual family circumstances that make camp especially important for the child:

Child's Emotional/Behavioral History:

	Often	Sometimes	Not at all
Aggresiveness
Betwetting
Biting
Eating Disorders
Hyperactive
Learning Disabilities
Lying
Night Terrors
Nightmares
Runs Away
Sexual Acting Out
Steals
Tantrums
Withdrawn

Please describe any details you wish to include about any of the above selections:
Has the child attended a Royal Family Kids Camp? If yes, where and when?
Camper t-shirt size:

Child SmallChild MediumChild LargeAdult SmallAdult MediumAdult LargeAdult XL
Does the child have any allergies?
Does the child have any dietary restrictions? If yes, please list the items the child cannot eat or drink.
Indicate all known allergies and reactions, severe illnesses, disabilities, physical limitations or medical conditions:
Disabilities or Limitations:

Leg or arm bracesHearing aidEating disorder
Indicate date of illness, severity, complications, and any residual impairments:
Are there any activities to be restricted?
Date of last Tetanus shot:
Please list the child's doctor, including name and phone number:
Is your child taking any prescription medications?

YesNo
If yes (to prescription medications) please type in the name of medication, dosage and time of day for medication to be administered:
What are the medications for?
MEDICATION STATEMENT:

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 the camp medical personnel to administer the above medication from July 10-13, 2023.
If your child requires medication, please initial here to confirm you are agreeing to allow the camp medical personnel to administer the medications.
Child's Medicaid Number:
MEDICAL RELEASE STATEMENT:

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 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, at a hospital, camp or elsewhere. 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/parent. I give my permission for the child listed in this application to attend Royal Family Kids Camp during the dates of July 10-13, and accept that the camp is being sponsored by Hedgemakers International and First Baptist Church Colville.
Initial below to agree to the medical release:*
PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATIONS

I hereby give the Royal Family Kids’ Camp medical personnel permission to administer the following products according to manufacturer’s instructions, or as otherwise specified.

I trust the RFKC medical personnel to use his/her best judgment as situations arise, and if in doubt, he/she can call for verification.

This must be completely filled out by the primary caregiver who signs this form, or the child may not attend camp.
Initial below to agree to over-the-counter medications statement:*

Please select YES or NO for the medications listed below.

	Yes	No
Sunblock
Insect Repellant
Lip Balm
Rash Ointment
Tylenol
Antiseptic Ointment
Band-Aids
Anti-itch Cream
Hydrogen Peroxide
Cough Syrup
Cough Drops
Decongestant
Antihistamine
Ipecac Syrup
Tums/Pepto Bismol

Other OTC medications not listed above:
Person authorized to pick up child on Thursday at conclusion of camp:
Liabilty Release: "Royal Family Kids Camp is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforseen events can occur. By signing this form, the parent or guardian agrees to assume and accept all risks and hazards inherent in camp activites. They also agree not to hold RFKC, First Baptist Church, Hedgemakers International Foundation or its volunteers liable for damages, losses or injuries to the person or property undersigned. The parents, guardians or caregivers understand that they are signing for the minor listed on this form and the signature is for the liability release."
Type first and last name of child's legal guardian:
Parent or Legal Guardians signature:

Clear
Date

MonthDayYear
Date

Camp Registration Fee:

USDCamp Registration Fee

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

PLEASE DO NOT ALLOW YOUR CHILD TO BRING THE FOLLOWING ITEMS TO CAMP: PHONES; TABLETS; MONEY; WEAPONS (INCLUDING POCKET KNIVES). THIS IS TO ENSURE THE SAFETY OF ALL CAMPERS AND VOLUNTEERS.
Should be Empty:

Camper Application

Royal Family Kids Camp, July 10-13, 2023