CAMPER REGISTRATION FORM 2025

2025 Camper Application
Sponsored by

Carlinville First Church

18772 Rt 4, Carlinville, IL 62626

Question call Denise Joiner

Child placement coordinator 217-473-5070

CAMP DATES JULY 28th-August 1st
INSTRUCTIONS: Please fill out all required fields.

The information is vital to the health and well being of the child.
Child's Legal Name*

First NameLast Name
Preferred Name*
Sex*
Birthdate*

MonthDayYear
Date
Age*
Current Emotional Age*
School*
Grade*
Mailing Address*
house number, street name and/or PO Box
City*
Zip*
The child is living with: (Check one)*

Foster Parent(s)Group HomeRelativeAdoptive Parent(s)Biological Parent(s)
Name(s) of person(s) the child is living with*
Home/cell number of caregivers*
Work phone number*
Emergency Contact Name*
Relationship to Child*
Phone number for emergency contact*
Caseworker's name*
Caseworker's phone number*
Moved in Foster Placement how many times?*
Explain any unusual family circumstances that make camp especially important for the child: (for example: recent crisis, being moved in foster placement, severe economic needs, etc.)
This child's swimming ability is:*

goodpoordo not know
Does this child have any learning disabilities?*

yesno
Reading Level*
Has the child attended a Royal Family Kids Camp before?*
Yes, where?
Camper T-Shirt Size*

Child SmallChild MediumChild LargeAdult SmallAdult MediumAdult LargeAdult XL
Camper Shoe Size*
Birthday Gifts

We have listed suggested gifts for both boys and girls. Please talk with your child and ask them which gifts they would like to receive. You can mark as many as you like.
Gift Ideas*

RC CarLego SetArt SetScience KitSport AccessoriesTeam ApparelHead Phones/EarbudsAction FiguresPokemon CardsBoard GameCard GamesNerf GunWatchWalletDress UpsDroneSquishmellowsBracelet Making KidsNail ArtSlimePurseMake Up SetHair AccessoriesBarbiesFashion Design KitsFidgetsOther
Please give more details for any of the above gifts. Or other specific gifts your child would like.*
My child's favorites things include:*
Examples: Color, TV show, Sports Team, Hobbies,
Trauma Informed Camper Information Instructions:

Please complete this portion in full. It may require information from the case worker as well.

Briefly explain anything marked with a yes*

	Yes	No	Description
Aggression (physical, verbal, property destruction, harming animals, fire starting)
Bedwetting (medical condition, trauma reaction, behavioral stage)
Disordered Food Behaviors (hoarding, under eating, overeating, medical issues)
Hyperactive (impulsive, inattentive)
Cognitive Issues (delays in reading/writing, comprehension, issues following instructions)
Dishonest/Secrecy (when fearing punishment, judgement)
Night Terrors (remains asleep, no memory of it Sleep Issues (nightmares, sleep walking/talking)
Elopement (impulsive, as a coping mechanism)
Sexual Acting Out (physical, verbal, independent/with others, exposure to materials)
Theft (to meet a need, hoarding behavior)

Please mark any of the following that the camper has experienced, that you have been made aware of:*

physical abuseincarcerated parenthate crimesexual abuseabsent parentdiscriminationemotional abuseloss of caregiverbullyingdomestic violencelabor exploitationtruancyfood insecuritysex traffickingemotionally unavailable caregiverhousing insecurityphysical restraintcaregiver w/mental illnessneglectabandonmentcaregiver w/substance abuseunsafe caregivernatural disasterinvolvement in criminal acts
What does it look like when your camper is..
Happy*
Upset*
Angry*
Lonely*
Tired*
Hungry*
Fearful*
Please give details and description or examples to each question that pertain to the camper.
What are the best coping skills when feeling stressed?*
Description
Please name their trigger for negative behaviors?*
Description
What are things they struggle with at school?*
Description
What are things they struggle most with at home?*
Description
How do they interact with peers?*
Description
How do they interact with adults?*
Description
Do they sometimes get overwhelmed by their environment (sounds, lights, temperatures, etc)?*
Description
Do they have any sensory concerns (food, textures, clothing, etc)?*
Description
How do they respond to physical touch?*
Description
Is there a history of suicidal or homicidal ideation or gestures?*
Description
Is there any history of drugs use, alcohol, nicotine, or vaping?*
Description
What are the your favorite things about your camper?*
Description
Is there anything else we should know?*
Description
HEALTH HISTORY
Indicate all known allergies, illness, disabilities, physical limitations or medical complications:
Allergies*
Illnesses/medical complications*
Disabilities/Limitations,*
Does your camper have any of the following?

Leg or arm bracesHearing AidsGlasses or contacts
Mark any that your camper has experienced. Use the box below to add dates, severity, complications and any residual impairments

Respiratory ProblemsHypoglycemiaMusculoskeletal AllergiesHeart or CirculationDizzy SpellsFoot ProblemsPulmonary EdemaBack IssuesSeizure DisorderHay FeverAnaphylactic ShockPoison OakBalance ProblemsDiabetesFaintingInsect BitesDrug AllergyOther
Details from above:*
Any specific activities to be encouraged?*
Any specific activities to be restricted?*
Please list reason.
Immunization History:

Please attach a copy of your campers immunization records. If you can not attach a digital copy, a paper copy will need to be sent before your child will be accepted to camp.
Prescription Medications:

All medications sent to camp must be in the original container with the pharmacy label on it.

Prescription Medications

	Name	Dosage:	Times:
1.
2
3

What is(are) the medication(s) for
Doctor's Name*
Phone*
I hereby authorize RFKC's nurse to administer the above medication from July 29th- August 2nd, 2024
Signature of Parent or Legal Guardian ONLY If foster parent please just put an x in the space below*

Clear
Parent or Legal Guardian ONLY If foster parent please just put an x in the space below*
Printed Name
Date If foster parent, please put a 1 in the spaces below. We will get the legal guardian to fill out the date when they sign.*

MonthDayYear
Date
MEDICAL RELEASE FORM:
This health history is correct so far as 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 dagnosis 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 workerlother, I give my permission for the camper listed below to attend Royal Family Kids Camp in the summer of 2023 through Carlinville First Church.
Camper*
Child's Medicaid #*
Authorized Signature. If foster parent please just put an x in the space below.*

Clear
Printed Name If foster parent please just put a x in the space below*
Relationship to child
Date: If foster parent, please put a 1 in the spaces below. We will get the legal guardian to fill out the date when they sign.

MonthDayYear
Date
PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATIONS

Please mark YES or NO for the medications listed below. This form must be completely filled out by the primary caregiver who signs below, or the camper may not attend camp.

	YES	NO
Sunblock
Insect Repellant
Rash Ointment
Tylenol
Lip balm
Antiseptic ointment
Band-aids
Anti-itch cream
Hydrogen Peroxide
Cough Syrup
Cough Drops
Decongestant
Antihistamine
Ipecac Syrup
Other

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 RFKC Registered Nurse to use her best judgment as situations arise, and if in doubt, he/she can call for verification.
Parent or Legal Guardian's Printed Name If foster parent please just put an x in the space below*
Parent or Legal Guardian's Signature If foster parent please just put a period(dot)in the space below*

Clear
Parent or Legal Guardian's Phone # If foster parent please just put a 1 in the spaces below*
Authorized Pick Up Person
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Should be Empty:

2025 Camper Application

Birthday Gifts

Trauma Informed Camper Information Instructions:

What does it look like when your camper is..

Please give details and description or examples to each question that pertain to the camper.

HEALTH HISTORY

Immunization History:

Prescription Medications:

MEDICAL RELEASE FORM:

PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATIONS

Authorized Pick Up Person