Royal Family KIDS Clearfield: Camper Registration-2023

1
Camper Information * This field is required.
Child's First Name
Child's Last Name
Child's Preferred Name if they have one
Male
Female
Gender
Birth date
6 years old
7 years old
8 years old
9 years old
10 years old
11 years old
12 years old
Age at time of camp
Emotional age
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
Child will be in this grade in September 2023
2
EthnicityPlease select the child's ethnic background
Please Select
Please Select
White (non-hispanic)
White Hispanic
Hispanic
Asian
African-American
American Indian
Pacific Islander or Native Hawaiian
Prefer not to answer
Please select one
3
Is the child a returning RFK Camper?
Yes
No
Don't know
Yes/No
If yes, please tell us what year and what Camp they attended.
4
Please upload a recent head shot color photo of this child (within the last six months). Upload a JPG ONLY...do NOT upload a PDF or other file type **. You will not be able to upload a photo larger than 1 MB (or 1024 KB) in size.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
5
Child's T-shirt size* This field is required.
Please Select
Please Select
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
6
Child's Shoe size* This field is required.
7
Name of Person Filling out this application:* This field is required.
First Name
Last Name
Caseworker
Foster Parent
Adoptive Parent
Biological Parent
Relative
Other
Relationship type
Please enter your phone
Please enter your email
8
Our Mentoring Program is a monthly event on the third Saturday of each month from 9-11:30 where your child is loved and mentored through games, arts and crafts, a bible lesson and more! Are you interested in finding out how your child can be part of the Elevation Church RFK Mentoring Program throughout the 2022-2023 school year?* This field is required.
Yes - I'm interested in the Mentoring Program. Please send me the forms to sign my child up!
Maybe - Please send me more information!
No, thank you.
9
Does this camper have a sibling wanting to attend this camp?* This field is required.
YESNO
10
If a sibling of this child is planning on camp this year, please tell us who that is:PLEASE FILL OUT AN INDIVIDUAL APPLICATION FOR EACH SIBLING.
1st sibling full name
Biological Sibling
Foster Sibling
Sibling in Adoptive Family
Other
Relation of 1st sibling is:
2nd sibling full name
Biological Sibling
Foster Sibling
Sibling in Adoptive Family
Other
Relation of 2nd sibling is:
3rd sibling full name
Biological Sibling
Foster Sibling
Sibling in Adoptive Family
Other
Relation of 3rd sibling is:
11
Child's home environment* This field is required.
Foster Home
Adoptive Parents
Group Home
Residential Treatment
Relative
Biological Parent(s)
12
Parent/Legal Guardian* This field is required.
First Name
Last Name
Relationship to child
Please enter the best phone number to contact you
Please enter your email
13
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
Child's home placements* This field is required.
What date was the child placed in the home?
At time of camp, how long will the child have been living in current home?
How many foster or residential placements has the child had, including the current home?
15
Who is the authorized adult who will be picking the child up on Friday, June 30, 2023? *GOVERNMENT ID REQUIRED** This field is required.
First Name
Last Name
Relationship to child
Please enter the best phone number to contact them
16
2nd Adult, if any, who is authorized to pick up the child at 2:00 pm on Friday, June 30, 2023? *GOVERNMENT ID REQUIRED*
First Name
Last Name
Relationship to child
Please enter the best phone number to contact them
17
Caseworker
Child's Placement/Caseworker Agency Name
Case Workers first name
Case Workers last name
Please enter best phone number to contact Case Worker
Please enter Case Worker email
18
2nd Caseworker, if any
Child's Placement/Caseworker Agency Name
Case Workers first name
Case Workers last name
Please enter best phone number to contact Case Worker
Please enter Case Worker email
19
CASA (Court Appointed Special Advocate) (if the child has one)
CASA Advocate first name
CASA Advocate last name
Please enter best phone number to contact CASA Advocate
Please enter your email to contact CASA Advocate
20
Why would this child's attendance at RFKC be important? Why would you like to see him or her attend camp?* This field is required.
21
Bed Wetting
Never wets the bed
Rarely wets the bed
Frequently wets the bed
Wets the bed every night
Does this child wet the bed?
If "yes", please explain (i.e. wears pull-ups, don't drink liquids after certain time, medications, just need to be aware, etc.).
22
Aggressive behavior
Never aggressive
Rarely aggressive
Frequently aggressive
Always aggressive
Does this child display aggressive behavior?
Please explain any aggressive behavior.
What may trigger aggressive behavior, or to whom/what is the child aggressive?
23
Biting
Never bites others
Rarely bites others
Frequently bites others
Always bites others
Does this child bite other children or adults?
Please explain what triggers the child to bite.
24
Eating Disorders/Food Issues
Anorexia
Bulimia
Overeating/Gorging
Hording or Stealing food
No eating disorders
Does this child deal with any eating disorders or have issues around food?
Please explain.
25
Hyperactivity
Very calm
Somewhat hyperactive
Frequently hyperactive
Always hyperactive
Is this child hyperactive?
Please describe this hyperactivity.
26
Attention span
Terrific attention span
Sometimes needs redirecting
Attention constantly needs redirecting
Very short attention span
How would you describe the child's attention span? Please explain.
27
Learning Difficulties
Hearing impairment
Vision impairment
Dyslexia or reading difficulties
None
Other
Child's reading level
Are there any learning difficulties that may affect this camper's week?
Please elaborate on any information that would help us make camp better for your child.
28
Lying
Does this child lie?
Please explain.
29
Sleeping Concerns
Please explain what triggers any nightmares or night terrors.
Please explain what calms or helps the child if they have nightmares or night terrors.
In general, does the child have any difficulty sleeping? If so, what helps them to get to sleep?
Has the child slept away from home before? If so, any concerns we should know about?
30
Running away/avoiding a situation.
Never runs away
Rarely runs away
Frequently runs away
Always runs away
Does this child run away from or avoid a situation? If so, how often?
Please explain what triggers running and/or what calms or helps the child.
31
Please let us know if -or how- the child may act out sexually.
Does not act out sexually
Touches self
Touches other children
Flirts or pays inappropriate attention to others
Makes inappropriate sexual comments
Does this child have a sexual history? If so, please explain.
Does this child act out sexually? If so, please describe what situations or triggers may contribute to this behavior.
32
Stealing
Never steals
Rarely steals
Frequently steals
Always steals
Know of stealing in the past, but not currently
Does this child steal things?
If so, please elaborate.
33
Tantrums/Anger Issues
Does not have tantrums or anger issues
Rarely has tantrums or anger issues
Frequently has tantrums or anger issues
Always has tantrums or anger issues
How often does this child have tantrums or anger issues?
What are potential "triggers" for the tantrums or anger?
Please describe what an overwhelming anger issue might look like.
Please describe possible alternatives to help calm the child.
34
Withdrawing
Never withdrawn
Rarely withdrawn
Frequently withdrawn
Always withdrawn
Does this child occasionally withdraw from people or situations?
Please explain.
35
Autisim
Mild
Moderate
Extreme
Does not have signs of autistim
How does this child rate on the Autism scale?
Please explain
36
Check all the boxes that are true about the child.* This field is required.
Creates a lot of noise
Craves bright lights, colors or busy pictures
Likes to crash and bump into people, walls, etc.
Use a lot of force when touching, hugging, or with "high fives"
Stomp feet when walking or kick feet when sitting
Like to be under heavy blankets to sleep
Love to spin or swing
Like to hang upside down
Unaware of messiness on hands or face
Like to get dirty
Like bare feet
Dislike heavy backpacks or heavy blankets
Become very upset when bumped or pushed, even by accident
Dislike spinning or doing summersaults
Get dizzy easily
Dislike being upside down
Dislike being picked up or moved
Dislike when his/her feet leave the ground
Dislike tags in clothing, seams in socks, etc.
Sensitive to certain types of fabrics in clothing and/or sheets
None of these apply
37
Please explain any information that addresses the boxes you checked above. Please include any information you think we should be aware of.* This field is required.
38
Please tell us about this child's history or story. What situations may have been challenging for this child before living in your home? How long and why was this child placed in foster care? What circumstances is this child currently dealing with?* This field is required.We expect and look for great things in each and every child. We also know that many of these children have had difficulties in their past which have shaped their present reality. Please give some information about his or her past so we can better understand this child.
39
If this child attended Royal Family KIDS' Camp in the past, what did he or she like about it? What positive changes or behaviors did you see upon their return home?
40
Please let us know strengths and great, positive things about this child. Please write as much as you'd like!* This field is required.What does he or she do well? Good, positive traits and characteristics? Things in which you can be proud of this child?
41
Please tell us what this child's interests, passions, loves, etc. are so our Staff can make camp even more special! (i.e. Loves sports or crafts, favorite food, favorite animal, favorite color...whatever!)* This field is required.
42
At Camp, we have a ratio of 2 campers of similar age paired together with 1 counselor/mentor, and then 2 counselors/mentors paired together with their campers.
Would this scenario work well for your child? Please explain any thoughts regarding how your child would thrive in this scenario.
43
Any additional behavior information you need for our staff or counselors to know while your child is at camp?Please share anything that might be helpful!* This field is required.
44
Doctor Information* This field is required.
Physicians full Name
Physicians phone number
Child's medicaid/insurance number
Date of child's last physical
Yes
No
Is child current on vaccinations?
Please explain if child is not current on vaccinations.
45
Illnesses and Medical Complications Past or Present (check all that apply)* This field is required.
Respiratory Problems
Muscuoskeletal Allergies
Food Allergies
Medicine Allergies
Topical Allergies (lotion, sunscreen, etc.)
Dizzy Spells and/or Fainting
Foot Problems
Back Problems
Seizure Disorders
Anaphylactic Shock
Balance Problems
Asthma
ADD or ADHD
Hypoglycemia
Heart or Circulation Problems
Pulmonary Edema
Hay Fever
Poison Oak/Poison Ivy Allergies
Type 1 Diabetes (previously insulin-dependent)
Type 2 Diabetes (previously non-insulin dependent)
Insect Bite Allergies (i.e. mosquitoes, bees, wasps, etc.)
Recent Surgery
Recent Broken Bones
Phyiscal limitations
Ear Infections
Hepatitis A, B, or C
Learning Disability
Constipation
Diarrhea
Fainting
None
46
Please explain any information that addresses the boxes you checked above. Please include any and all additional medical issues we should be aware of.* This field is required.
47
List all known allergies to food, plants, medications, animals, etc.* This field is required.
48
Please check YES or NO giving us approval to administer 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
Acetaminophen (Tylenol) 325mg tabs
Acetaminophen Liquid (Tylenol) 160mg/5ml
Ibuprofen (Advil) 200mg tabs
Ibuprofen Liquid (Advil) 100mg/5ml
Diphenhydramine (Benadryl) 25mg tabs
Diphenhydramine Liquid (Benadryl) 12.5mg/5ml
Dextromethorphan (Delsym) 15mg/5ml
Calcium carbonate chewable (TUMS)
Cough Drops (generic)
Phenol spray (Chloraseptic spray)]
Triple antibiotic ointment (neosporin)
Hydrocortisone cream 1%
Hydrogen Peroxide OTC
Solarcaine topical
Immodium
Pepto Bismal liquid and chewables
Calamine or Caladryl Lotion
Lice treatment/shampoo
Bactine (first aid/antiseptic/pain reliever)
Sunscreen
Acetaminophen (Tylenol) 325mg tabs
Acetaminophen Liquid (Tylenol) 160mg/5ml
Ibuprofen (Advil) 200mg tabs
Ibuprofen Liquid (Advil) 100mg/5ml
Diphenhydramine (Benadryl) 25mg tabs
Diphenhydramine Liquid (Benadryl) 12.5mg/5ml
Dextromethorphan (Delsym) 15mg/5ml
Calcium carbonate chewable (TUMS)
Cough Drops (generic)
Phenol spray (Chloraseptic spray)]
Triple antibiotic ointment (neosporin)
Hydrocortisone cream 1%
Hydrogen Peroxide OTC
Solarcaine topical
Immodium
Pepto Bismal liquid and chewables
Calamine or Caladryl Lotion
Lice treatment/shampoo
Bactine (first aid/antiseptic/pain reliever)
Sunscreen
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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49
What specific activities should we ENCOURAGE your child to do while at camp?
50
What specific activities should be DISCOURAGED for medical reasons while at camp?
51
Will your child be bringing Prescription and/or Over-the-Counter Medications?* This field is required.
YESNO
52
I understand that it is my responsibility as a caregiver to make sure that all instructions are clear and that the necessary dosage is adequately supplied for the duration of camp. I authorize RFKC medical staff to administer the medications.* This field is required.
Yes, I understand it is my responsibility to supply clear instructions and medical dosage needed and agree for RFKC medical staff to adminster the medications.
No, I understand it is my responsibility to supply clear instructions and medical dosage needed. However, I don't agree for RFKC medical staff to administer the medications.
53
Prescription and/or Over-the-Counter medication: #1
Name of Medication
How long has the child been taking this medication?
Reason for taking the medication.
Dosage amount and Time of day to administer medication
54
Prescription and/or Over-the-Counter Medication: #2
Name of Medication
How long has the child been taking this medication?
Reason for taking the medication.
Dosage amount and Time of day to administer medication
55
Prescription and/or Over-the-Counter Medication: #3
Name of Medication
How long has the child been taking this medication?
Reason for taking the medication.
Dosage amount and Time of day to administer medication
56
Prescription and/or Over-the-Counter Medication: #4
Name of Medication
How long has the child been taking this medication?
Reason for taking the medication.
Dosage amount and Time of day to administer medication
57
Prescription and/or Over-the-Counter Medication: #5
Name of Medication
How long has the child been taking this medication?
Reason for taking the medication.
Dosage amount and Time of day to administer medication
58
Prescription and/or Over-the-Counter Medication: #6
Name of Medication
How long has the child been taking this medication?
Reason for taking the medication.
Dosage amount and Time of day to administer medication
59
Please provide any additional information we need to know about any prescription drugs, vitamins, and/or over-the-counter medications sent to camp.* This field is required.
60
Permission to Travel, Waiver and Release of Liability* This field is required.
61
Date* This field is required.
Date
Year
Month
Day
62
Authorized Signature: I have read the above "Permission to travel, waiver and release of liability" in the Terms & Conditions and by signing below I agree. It is my intention to exempt and relieve Elevation Church, For The Children, and Royal Family KIDS Camp leadership from all and any liability. Sign by using your mouse pad or touch screen.* This field is required.
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