• 2026 Camper Application

    2026 Camper Application

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    Sponsored by

    Carlinville First Church

    18772 Rt 4, Carlinville, IL 62626

    Question call Denise Joiner

    Child placement coordinator 217-473-5070

    CAMP DATES JULY 27th-JULY 31st

     

  • INSTRUCTIONS: Please fill out all required fields.  

    The information is vital to the health and well being of the child. 

     

  • Birthdate*
     / /
  • The child is living with: (Check one)*
  • This child's swimming ability is:*
  • Does this child have any learning disabilities?*
  • Camper T-Shirt 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*

  • Trauma Informed Camper Information Instructions:

    Please complete this portion in full. It may require information from the case worker as well.
  • Rows
  • Please mark any of the following that the camper has experienced, that you have been made aware of:*

  • 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

  • Indicate all known allergies, illness, disabilities, physical limitations or medical complications: 

  • Does your camper have any of the following?
  • Mark any that your camper has experienced. Use the box below to add dates, severity, complications and any residual impairments

  • Immunization History:

    Please email a copy of your child's immunization records and insurance/medical card to royalfamily@carlinvillefirst.org or text a picture to our Childe Placement Coordinator Denise at 217-473-5070

  • Prescription Medications:

    All medications sent to camp must be in the original container with the pharmacy label on it. And please only send enough medication for the week.
  • Rows
  • Format: (000) 000-0000.

  • I hereby authorize RFKC's nurse to administer the above medication from July 27th- July 31st, 2026

  • Date If foster parent, please put a 1 in the spaces below. We will We will get the legal guardian to fill out the date when they sign.*
     / /

  • 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 2026 through Carlinville First Church.

  • 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.
     / /

  • PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATIONS

  • Rows

  • 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. 

  • Format: (000) 000-0000.

  • Authorized Pick Up Person

  • Format: (000) 000-0000.
  • Should be Empty: