Camper Application
Camp by Activate Church Huntington Beach
Camp Information
Camp Dates: July 4-8
Child’s Full Name
*
First Name
Last Name
Preferred Name
Photo of Child
Browse Files
Cancel
of
Sex
*
Birthdate
*
/
Month
/
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School
*
Grade
*
Reading Level
*
The child is living with: (Check One)
*
Foster Parent
Group Home
Relative
Name of Guardian the child is living with
*
First Name
Last Name
Name another guardian if applicable
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Guardian Email
example@example.com
Cell Phone
First Name
Last Name
Emergency Contact
Emergency Phone Number
-
Area Code
Phone Number
Relationship to Child
Social Worker Name
Social worker phone
-
Area Code
Phone Number
Moved in foster placement how many times?
Explain any unusual family circumstances that make camp especially important fo this child: (For example” recent crisis, being moved in foster placement, sever economic needs, etc.)
Campers Emotional / Behavioral History
Aggressiveness
*
Often
Sometimes
Never
Bedwetting
*
Often
Sometimes
Never
Biting
*
Often
Sometimes
Never
Eating Disorders
*
Often
Sometimes
Never
Hyperactive
*
Often
Sometimes
Never
Learning and Disabilities
*
Often
Sometimes
Never
Lying
*
Often
Sometimes
Never
Night Terrors
*
Often
Sometimes
Never
Nightmares
*
Often
Sometimes
Never
Runs Away
*
Often
Sometimes
Never
Sexual Acting Out
*
Often
Sometimes
Never
Steals
*
Often
Sometimes
Never
Tantrums
*
Often
Sometimes
Never
Withdrawn
*
Often
Sometimes
Never
Extreme Anger
*
Often
Sometimes
Never
Details from above:
This child’s swimming ability is”
Good
Poor
Do not know
Learning Disabilities:
Yes
No
Reading Level
Has this child attended Royal Family Kids Camp before?
Yes
No
If so, where”
Child T-Shirt Size (Please choose an appropriate size that fits the child)
Child Small
Child Medium
Child Large
Adult Small
Adult Medium
Adult Large
Health History
Indicate all known allergies, illness, disabilities, physical limitations or medical complications:
Allergies:
Illnesses / Medical complications:
Disabilities / Limitations:
Does the child have any of the following:
Leg or Arm Braces
Hearing Aids
Eating Disorderd
Indicate date of illness, severity, complications, and any residual impairments.
Respiratoryu Problems
Heart or Circulation
Pulmonary Edema
Hay Fever
Balance Problems
Insect Bites
Hypoglycemia
Dizzy Spells
Back
Anaphylactic Shock
Diabetes
Drug Allergy
Musculoskeletal Allergies
Foot
Seizure Disorder
Poison Oak
Fainting
Other
Details from above:
Any specific activities to be encouraged?
Any specific activities to be restricted?
IMMUNIZATION HISTORY
Please fill in dates of basic immunizations and most recent booster as best as you can.
DTP Series
List date as best you can
DTP Booster
List date as best you can
Typhoid
List date as best you can
German Measles (Rubella)
List date as best you can
Tetanus Booster
List date as best you can
Measles Vaccine (live)
List date as best you can
Mumps Vaccine (live)
List date as best you can
Polio OPV (Sabin)
List date as best you can
Tuberculin (TB) Test
List date as best you can
Small Pox
List date as best you can
PRESCRIPTION MEDICATION
ALL MEDICATION SENT TO CAMP MUST BE IN ORIGINAL CONTAINER WITH THE PHARMACY LABEL ON IT.
Is you child taking any medications?
*
Yes
No
Name of medication #1:
Dosage of medication #1:
Times of day (medication #1):
Name of medication #2:
Dosage of medication #2:
Times of day (medication #2):
Name of medication #3:
Dosage of medication #3:
Times of day (medication #3):
What is (are) the mecication(s) for?
Doctor’s Name
*
Doctor’s Phone Number
*
-
Area Code
Phone Number
Please add any additional comments related to the HEALTH and MEDICATIONS here:
AUTHORIZATIONS
I understand that it is my responsibility as caregiver to make sure that all instructions are clear and that necessary dosage is adequately supplied for the duration of damp. I hereby authorize RFKC’s nurse to administer the above medication from June 15, 2020 to June 19, 2020.
Parent or Legal Guardian Printed Name
*
First Name
Last Name
Parent or Legal Guardian Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
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