Camper Application - Summer 2023

Love Fosters Hope Camper Application - Summer 2023
Love Fosters Hope provides free sleep over summer camps for children and teens between the ages 7 to 19 years old and who are in the foster care system.
Select the appropriate camp according to the camper's age and sex. Camp dates run from June through July.*

7 to 11 year old Co-ed Royal Family Kids Camp June 5th-9th, 202312 to 15 year old Teen Reach Adventure Camp for Girls June 21st to 24th, 202312 to 15 year old Teen Reach Adventure Camp for Boys, June 28th - July 1st16 to 19 year old Co-ed Bridge Camp July 12th-15th, 2023
Camper INFORMATION

You must complete the entire application for each child.

All information will be kept confidential.
Camper's Name*

First Name (LEGAL)Last Name (LEGAL)PREFERRED First Name (NICKNAME)
Gender at Birth*

MaleFemale
T-shirt Size*

Child SChild MChild LAdult SAdult MAdult LAdult XLAdult 2XLAdult 3XL
Birth Date*

MonthDayYear
Actual Age*
Mental Age*
Emotional Age*
Grade (current school year: 2022-2023)*
For Bridge Camp ONLY (estimated year of high school graduation)
BOYS Shoe Size
BOYS Pants Size
GIRLS Shoe Size
GIRLS Dress Size
GIRLS Bra Size
Ethnicity (information needed for the purpose of obtaining grants)*

Hispanic or LatinoNon-Hispanic or Latino
Race (information needed for the purpose of obtaining grants)*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
Child or teen's PERSONALITY (mark ALL traits that describe the camper MOST of the time)*

SocialSeriousDeterminedPerformerEnergeticPlannerPeacekeeperKindTalkerShyAthleticOptimisticHumorousOrderlyObserverNegativeQuietCompetitivePerfectionistLeader
Child or teen's INTERESTS (mark ALL interests of the camper)*

ReadingArts/CraftsShoppingDancingMusicSingingRappingMoviesActingHikingCard GamesSwimmingIndoor ActivitiesOutdoor ActivitiesVideo GamesPlaying Board Games
Has the child or teen attended any of our camps IN THE PAST? If so, mark which ones.*

Royal Family Kids Camp (ages 7-11)Teen Reach Adventure Camp (ages 12-15)Bridge Camp (ages 16-19)Camper has not attended any of the camps listed above
LEGAL GUARDIAN RELATIONSHIP
Name of person with whom teen is living*

First NameLast Name
What name does this child call his/her current guardian/emergency contact? *
Legal Guardian Relationship to youth.*

Foster ParentAdoptive Parent - Adopted children will be placed on a wait list and considered after all foster children have been placed.Group HomeKinship placementBio Parent (Please note that children residing with Bio Parents are NOT eligible for RFKC.)
If you answered Kinship placement on the previous question, select the relationship to the child. *
Address*

Street Address

Street Address Line 2

CityZIP Code

County
Home Number

Area CodePhone Number
Cell Number*

Area CodePhone Number
Work Number

Area CodePhone Number
E-mail*
example@example.com
Length of time the child has lived in this home. (Ex: 2 weeks, 8 months, 1 year) *
Names and ages of other foster children living in this home. Please include First Name, Last Name, Age, & if you have submitted an application for this child to also attend one of our camps. If yes, which one? Please list N/A if not applicable. *
CASE WORKER INFORMATION
Case Worker's Name*

First NameLast Name
Case Worker’s Phone Number*

Area CodePhone Number
Case Worker’s E-mail*
example@example.com
Case Worker’s County*
Case Worker Supervisor's Name

First NameLast Name
Supervisor's Phone Number

Area CodePhone Number
Supervisor’s E-mail
example@example.com
MEDICAL HISTORY
Doctor's Name*

First NameLast Name
Doctor's Phone Number*

Area CodePhone Number
Facility Name*
Health Insurance/Medicaid*
Health Insurance/Medicaid Policy Number*
Approved Medical Facility
Emergency Prescription Source
Emergency Prescription Source's Phone Number

Area CodePhone Number
Are your child's immunizations current?*

YESNO
If you selected YES to the previous question about immunizations being current, please list the name of the PUBLIC SCHOOL the child is attending. If you selected NO, please write "will e-mail record" & e-mail the immunization record once it is up to date to Love Fosters Hope Program Officer, Cynthia Turner, at cynthia@lovefostershope.org.*
Does the youth have seasonal allergies?*

YesNo
Please list specific allergy and severity (mild, moderate, life-threatening) of allergic reaction. Put N/A if not applicable. *
Medication required to treat allergy. (Put N/A if not applicable to you.) *
Does the youth have food/drug allergies?*

YesNo
Please list specific allergy and severity (mild, moderate, life-threatening) of allergic reaction. Please put N/A if not applicable. If a PEANUT ALLERGY, RFKC CANNOT ensure that campers are not exposed to peanuts/or peanutbutter, therefore unfortunately we CANNOT accommodate a child with peanut allergies at our camp. *
Medication required to treat allergy. (Please put N/A if not applicable) *
Is the youth allergic to bees?*

YesNo
Please list severity (mild, moderate, life-threatening) of allergic reaction. (Please put N/A if not applicable) *
Medication required to treat allergy: (Please put N/A if not applicable.) *
Does the youth carry an epi pen?*

YesNo
List ANY of the child's known medical conditions (mental or physical), illnesses or surgeries treated by a doctor. If none, type “N/A"*
List ANY physical disabilities or other limitations that would help us better care for your child. (Select all that apply).*

AutismCerebral PalsyIntellectual DisabilityOrthopedic ImpairmentADHDVisually ImpairedEmotional DisturbanceHearing ImpairedODD - Operational Defiance DisorderNone
Is the child diabetic? If yes, we must have a medical release signed by their doctor*

YesNo
Is the teen pregnant? If yes, the teen must have a medical release signed by her doctor*

YesNo
Does the child have asthma? If yes, the teen must have a medical release signed by their doctor*

YesNo
Please list ALL medications the child or teen is currently taking (including over-the-counter drugs). NOTE: MEDICATIONS MUST BE IN ORIGINAL PRESCRIPTION BOTTLES FROM PRESCRIBING PHYSICIAN. If none, type “N/A"*
EMOTIONAL AND BEHAVIORAL HISTORY
What difficult events has this child experienced in their lifetime (that you are aware of)? Check all that apply.*

Death of a loved oneIncarceration of a loved onePhysical abuseVerbal abuseSexual abuseWitnessing violence (domestic or otherwise)Exposure to substances (drugs/alcohol)NeglectMedical traumaBullying
Please describe the relationship this child has with his/her current guardian/emergency contact. (Check any that apply)*

CaringRespectfulCloseFearfulSubmissiveGuardedDefiantDisrespectfulDistantTense

Indicate with an "X" the degree to which the child displays the following emotions/behaviors. Please answer honestly. Negative behaviors do not disqualify the child from participating in our programs.*

	FREQUENTLY	SOMETIMES	NEVER
Aggression/Anger
Bedwetting
Biting
Hyperactive
Learning Difficulties
Lying
Nightmares
Night Terrors
Runs Away
Tantrums
Acting Out Sexually
Stealing
Withdrawn
Night Walking
Eating Disorder

For Eating Disorders, select all that apply.*

Taking/Hiding/Hoarding foodUncontrolled EatingAnorexiaN/A - Not applicable
Please list triggers (words, phrases, items, or actions) and calming methods (distraction, quiet time, special toy/blanket, calling current guardian) for all "sometimes" & "frequent" behaviors selected on previous question. *
How does this child typically respond to new adults? Check any that apply.*

Compliant/follows directionsDefiant/Pushes against the rulesTries to push boundariesTries to pleaseNeeds gentlenessNeeds assertivenessRespectfulDisrespectfulOther
If this person is female, is she fearful of men? If yes, please explain. Our programs have both men and women who serve in various roles. All our volunteers have been carefully screened and trained. Please put N/A if this person is male. *
Is there anything else we should know about your child in order to better meet their needs?*
Does your child have any criminal history? Please list any pending charges/cases, probation, etc. Please put N/A if not applicable. *

Legal Guardian Consent

As Legal Guardian of the named teen, I hereby agree that all information provided to Love Fosters Hope is correct and I approve their participation in the Love Fosters Hope Mentoring Program.
Legal Guardian Name*

First NameLast Name
Legal Guardian Signature*

Clear
Date*

MonthDayYear
Date
Teen Name (if age 18 and above)

First NameLast Name
Teen Signature (if age 18 and above)

Clear
Date

MonthDayYear
Date
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Love Fosters Hope

33300 Egypt Lane, Suite G420

Magnolia, TX 77354

www.lovefostershope.org
Should be Empty:

	YES	NO
Sunscreen
Insect Repellant
Lip Balm
Rash Ointment
Tylenol
Ibuprofen
Antiseptic Ointment
Band-Aid
Anti-itch Cream
Alcohol Wipes
Cough Syrup
Cough Drops
Decongestant
Antihistamine
Pepto-Bismol
Tums
Other

Love Fosters Hope Camper Application - Summer 2023

Camper INFORMATION

LEGAL GUARDIAN RELATIONSHIP

CASE WORKER INFORMATION

MEDICAL HISTORY

EMOTIONAL AND BEHAVIORAL HISTORY