2023 Camper Application

Camper Application

Camp by Activate Church Huntington Beach
Camp Information

Camp Dates: June 19-23, 2023
Instructions: This form must be completely filled out. The information is vital to the health and wellbeing of the child. Search Policy: For the success and safety of all camp attendees, it may be necessary to search a child’s bags or property to assure they have everything they need for a successful week (i.e. clothing, swimsuit, toiletries, etc.) and a safe week (i.e. no candy, electronics, tobacco products, or other inappropriate items.) Any Illegal items will be turned over to proper authorities be that the Guardian, Social Worker or Law enforcement and the Guardian will be informed. Any other items removed will be returned directly to the legal Guardian at registration, if possible, or at the end of the camp.
Child’s Full Name*

First NameLast Name
Preferred Name
Photo of Child

Browse Files

Cancelof
Sex*
Birth date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School*
Grade*
Reading Level*
The child is living with: (Check One)*

Resource ParentGroup HomeRelative
Name of Guardian the child is living with*

First NameLast Name
Name another guardian if applicable

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Guardian Email
example@example.com
Cell Phone

First NameLast Name
Emergency Contact
Emergency Phone Number

Area CodePhone Number
Relationship to Child
Social Worker Name
Social worker phone

Area CodePhone Number
Moved in foster placement how many times?
Explain any unusual family circumstances that make camp especially important fo this child: (For example” recent crisis, being moved in foster placement, sever economic needs, etc.)
Campers Emotional / Behavioral History
Aggressiveness*
Bedwetting*
Biting*
Eating Disorders*
Hyperactive*
Learning and Disabilities*
Lying*
Night Terrors*
Nightmares*
Runs Away*
Sexual Acting Out*
Steals*
Tantrums*
Withdrawn*
Extreme Anger*
Details from above:
This child’s swimming ability is”
Learning Disabilities:

YesNo
Reading Level
Has this child attended Royal Family Kids Camp before?

YesNo
If so, where”
Child T-Shirt Size (Please choose an appropriate size that fits the child)
Health History

Indicate all known allergies, illness, disabilities, physical limitations or medical complications:
Allergies:
Illnesses / Medical complications:
Disabilities / Limitations:
Does the child have any of the following:

Leg or Arm BracesHearing AidsEating Disorder
Indicate date of illness, severity, complications, and any residual impairments.

Respiratory ProblemsHeart or CirculationPulmonary EdemaHay FeverBalance ProblemsInsect BitesHypoglycemiaDizzy SpellsBackAnaphylactic ShockDiabetesDrug AllergyMusculoskeletal AllergiesFootSeizure DisorderPoison OakFaintingOther
Details from above:
Any specific activities to be encouraged?
Any specific activities to be restricted?
IMMUNIZATION HISTORY

Please fill in dates of basic immunizations and most recent booster as best as you can.
DTP Series
List date as best you can
DTP Booster
List date as best you can
Typhoid
List date as best you can
German Measles (Rubella)
List date as best you can
Tetanus Booster
List date as best you can
Measles Vaccine (live)
List date as best you can
Mumps Vaccine (live)
List date as best you can
Polio OPV (Sabin)
List date as best you can
Tuberculin (TB) Test
List date as best you can
Small Pox
List date as best you can
PRESCRIPTION MEDICATION

ALL MEDICATION SENT TO CAMP MUST BE IN ORIGINAL CONTAINER WITH THE PHARMACY LABEL ON IT.
Is you child taking any medications?*

YesNo
Name of medication #1:
Dosage of medication #1:
Times of day (medication #1):
Name of medication #2:
Dosage of medication #2:
Times of day (medication #2):
Name of medication #3:
Dosage of medication #3:
Times of day (medication #3):
What is (are) the mecication(s) for?
Doctor’s Name*
Doctor’s Phone Number*

Area CodePhone Number
Please add any additional comments related to the HEALTH and MEDICATIONS here:
AUTHORIZATIONS

I understand that it is my responsibility as caregiver to make sure that all instructions are clear and that necessary dosage is adequately supplied for the duration of damp. I hereby authorize RFKC’s nurse to administer the above medication from June 19 to June 23, 2023.
Parent or Legal Guardian Printed Name*

First NameLast Name
Parent or Legal Guardian Signature*

Clear
Date*

MonthDayYear
Date
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Camper Application

Camp Information

Campers Emotional / Behavioral History

Health History

IMMUNIZATION HISTORY

PRESCRIPTION MEDICATION

AUTHORIZATIONS