Camper Registration Form

Camper Registration Form

Please complete this application form entirely in order to have your child's application considered for camp. If you have questions, please contact info@salemrfk.org.
Child's Full Name*

First NameLast Name
Gender assigned at birth*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate*

MonthDayYear
Date
Current Age (at time of submission):
Current Emotional Age (if known):
School:*
Grade:*
Reading level/comfortability:
Child's shirt size:
Child's pant size:
Child's shoe size:
The Child is living with (check one):*

Foster ParentGroup HomeRelativeBiological FamilyOther
Name of primary caregiver the child is living with:*

First NameLast Name
Name of any additional person(s) the child is living with:

First NameLast Name
Email of adult:*
example@example.com
Phone Number for adult:*
Please enter a valid phone number.
Phone number of additional person:
Please enter a valid phone number.
Emergency Contact:*

First NameLast Name
Emergency Contact Phone: *
Please enter a valid phone number.
Emergency Contact Relationship to Child:*
Case Worker*

First NameLast Name
Case Worker Phone Number:*
Please enter a valid phone number.
Case Worker Email:*
example@example.com
How many times has the child moved in Foster Care (if known):
Please check and explain any recent family circumstances that make camp especially important for this child:

Recent CrisisRecently came into careSeparated from siblingsRecently changed placementOther
Please explain your above answer:

Camper's Emotional / Behavioral History*

	Daily	Weekly	Monthly	Within in the last 6 months	Not at all
Agressiveness
Bedwetting
Biting
Eating Disorder
Hyperactive
Learning Disabilities
Lying
Night Terrors
Nightmares
Problems with sharing
Run Away
Sexually Acting Out
Stealing
Tantrums
Withdrawn

If you checked Daily or Weekly above, please describe the behaviors and suggestion to help the child.
Are there any additional significant behaviors we should know about this child?
Does the child have any difficulty with transitions? If so, please explain what that behavior looks like and what helps them transition. If not, please say none. *
Does the child have any emotional/behavioral triggers (noise, touch, etc.)?

YesNo
If yes, please explain:
What are good reinforcement rewards to promote positive behavior in this child (for example: stickers, coloring, stuffed animal, music, etc.)? Please do your best to not include things like tablets or TV, since they are not available at camp.
Does the child have any specific strengths / interests / preferred activities?
Does the child have any activities to be restricted or difficulty with certain activities?
Is there anything else you would like to tell us about this child or ways that they can be supported at camp? Any concerns?
Camper Details
This child's swimming ability is:*

GoodPoorUnknown
This child's comfort level around animals (farm animals, horses, llama, dogs, etc.):*

GoodPoorUnknown
Do you expect the child will change placements before, during or shortly thereafter the week of camp?

YesNo
Health History

Indicate all known allergies, illnesses, disabilities, physical limitations, or medical complications (if none or unknown, please write none or unknown):
Allergies:*
Illnesses / Medical Complications:*
Disabilities / Assistive Devices (leg or arm braces, hearing aids, glasses/contacts, etc.):*
Indicate date of illness, severity, complications, and any residual impairments. If none, other, or unknown, please fill in accordingly.
Respiratory illness: Type a label
Asthma:Type a label
Heart or circulation:Type a label
Frequent ear infections:Type a label
Hay fever:Type a label
Insect bites/stings:Type a label
Dizzy spells:Type a label
Anaphylaxis:Type a label
Diabetes:Type a label
Drug Allergy:Type a label
Seizure Disorders:Type a label
Poison Oak/Ivy:Type a label
Fainting: Type a label
Conjunctivitis (pink eye):Type a label
Skin rash:Type a label
Latex allergy:Type a label
Head lice:Type a label
Apendicitis:Type a label
Other or Unknown:Type a label
None: Type a label
Does the child have a mental health diagnosis? If yes, please explain or describe diagnosis (example: ADHD, PTSD, Separation Anxiety, Autism, Spectrum Disorder, etc.): *
Immunization History

Please fill in dates of basic immunization and most recent booster as best as you can.
DTaP Series Date   Booster Date
Hepatitis A Date
Hepatitis B Date
MMR Date
Tdap Date
Tuberculin (TB) Test   Date
Varicella Date
Unknown
Prescription Medication

All medications sent to camp must in the original container with the pharmacy label on it.
Is the child taking any medications? (Please include inhalers and epi-pens)*

Yes, please fill in the following information belowNo
Medication blanks Dosage blank Time taken Type a labelMedication blanks Dosage Type a labelTime taken
Medication blanks Dosage Type a label Time taken Type a label
What are the medications for:
Does the child have any challenges taking medication? If yes, please explain and offer suggestions to help the child.*
Doctor's Name and Office*
Doctor's Phone Number*
Please enter a valid phone number.
Please add any other comments relation to Health and Medications here:
I understand that it is my responsibility as caregiver to make sure all instructions are clear and that the information doesage is adequately supplied for the duration of camp. I hereby authorize RFK's Camp Nurse to administer the above medication from:
Date Camp Starts*

MonthDayYear
Date
Date Camp End*

MonthDayYear
Date
Child's Medicaid #*
Permission to Administer Over the Counter Medications

I hereby give the Royal Family KIDS' Camp Nurse permission to administer the following products according to manufacturer's instructions, or as otherwise specified. I trust the RFKC Nurse to use his/her best judgement as situations arise, and if in doubt, he/she can call for verification.

Please check Yes or No for the medications listed below. This must be completely filled out by the primary caregiver who signs below. Information is required for child to attend camp.*

	Yes	No
Tylenol
Ibuprofen
Anti-itch cream
Burn gel
Cough drops
Cough syrup
Decongestant
Antihistamine
Tums
Eye drops
Neosporin
Other

If other, please list below:
Medical Release Form:

This health history is correct so far as I know, and the above named minor has permission to engage in all the prescribed program activities, except as noted. The undersigned do hereby authorize the directors of Royal Family KIDS Camp Salem, 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 advisably 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 Ave, 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 invovled 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 stated child to attend Royal Family KIDS Camp through Family Life.
Legal Guardian Signature

Clear
Legal Guardian Name

First NameLast Name
Date

MonthDayYear
Date
Person Authorized to pick up child at the end of camp. This person will be required to show identification.

First NameLast Name
Should be Empty:

Camper Registration Form

Camper Details

Health History

Immunization History

Prescription Medication

I understand that it is my responsibility as caregiver to make sure all instructions are clear and that the information doesage is adequately supplied for the duration of camp. I hereby authorize RFK's Camp Nurse to administer the above medication from:

Permission to Administer Over the Counter Medications

Medical Release Form: