This application enables you to register children for RFK 2023 camp July 24th thru July 28th. The form asks information about the child's medical information, eating disorder, family history, and other questions for safety and security of the child. A small head shot photo of the child will need to be uploaded on the application. Please fill out ONE APPLICATION FOR EACH CHILD. Foster kids ages 7-11 are eligible for camp. Kids who have been adopted are allowed to attend camp, however kids who have not been adopted and/or returning are first priority when being accepted to camp. This application does not guarantee the child a spot at camp. You will be notified if the child has or has not been guaranteed a spot to camp no later than May. If you have any questions please email email@example.com or call our Child Placement Cordinator, Ashleigh Banks at 801-529-7784
Childs Preferred Name, if different from legal name:
Preferred First Name
Camp Date (Date Picker)
Date of Birth:
Age at time of camp:
Childs emotional age
Child's T-shirt size
Childs school grade
Childs reading level
Is the child a returning RFK camper?
If yes, please tell us what year(s)
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?
Please upload a recent head shot color photo of this child (within the last six months). Upload a JPG, or PNG ONLY. You will not be able to upload a photo larger than 1 MB (or 1024 KB) in size.
Upload a File
Drag and drop files here
Choose a file
Pacific Islander or Native Hawaiian
Prefer not to answer
Child's home environment
What date was the child placed in home:
How many foster or residential placements has the child had, including current home:
Siblings of Child Applying to RFKC This Summer
If sibling(s) of this child will also be applying to this camp, please provide their info so we can try and get all siblings to camp this summer. PLEASE MAKE SURE AN INDIVIDUAL APPLICATION IS SUBMITTED FOR THE OTHER SIBLING(S)
Does the child have a sibling/relative attending camp
If the child has siblings/relatives attending camp, please tell us their name(s):
First and Last name of siblings/relatives
Name of person filling out application:
Relationship of person doing app for child:
Phone Number of person doing app
Email of person doing app
Parent/Legal Guardian, same as person doing app
Parent/Legal Guardian Name:
Relationship of parent/legal guardian to child:
Phone Number of parent/legal guardian
Email of parent/legal guardian
Address of legal Guardian:
Street Address Line 2
State / Province
Postal / Zip Code
Emergency Contact, same as person doing app
Emergency Contact Phone #
Emergency Contact email
Authorized adult to pick child up at Mountain View Christian Assembly of God - 8000 S 300 E Sandy, Utah
Pick up time is 1:00pm Friday, July 28th 2023
Authorized to pick up child is same as person doing app
Name of authorized adult that will be picking the child up *GOVERNMENT ID IS REQUIRED*
Relationship to child of person picking up child
Phone Number of person authorized to pick the child up:
2nd person Name of authorized adult to pick the child up *GOVERNMENT ID IS REQUIRED*
Relationship of 2nd person authorized to pick up child
Phone Number of 2nd person authorized to pick the child up:
Caseworker/Child Placement Agency Information
Childs placement/caseworker agency name:
Childs placement/caseworker name:
Childs placement/caseworker phone #
CASA (Court Appointed Special Advocate) name, if the child has one
CASA Phone #
Please fill this out to the best of your ability. We as RFKC staff want to make sure your child has a safe, healthy, fun time at camp. This information is extremely helpful!
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?
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.
Why would this child's attendance at RFKC be important? Why would you like to see him or her attend camp?
How often does the child have nightmares?
Rarely has nightmares
Frequently has nightmares
Always has nightmares
How often does the child wet the bed?
Never wets the bed
Rarely wets the bed
Frequently wets the bed
Wets the bed every night
Wears a pull-up at night time
Any sleeping conecerns?
Does the child have difficulty falling asleep? Has the child slept away from home before? Does the child wear pull-ups? Please explain what may trigger these things and what helps in calming the child.
How good of a swimmer is the child (check all that apply)?
Not a good swimmer at all
Needs assistance of a floating device
Somewhat of a good swimmer
Is a great swimmer
Has to stay in shallow waters
Does the child display aggressive behavior?
Please explain more about the aggressive behavior?
Please explain what may trigger the behavior or to who the child is aggressive to and what helps when this behavior is displayed.
Does the child bite other children or adults?
Never bites others
Rarely bites others
Frequently bites others
Always bites others
Does the child have any eating disorders or issues around food (check all that apply)
Hording or Stealing food
No eating disorders
Please tell us what triggers the eating disorder?
Please explain what may trigger the eating disorder and what may help it.
How would you describe the child's hyperactivity(check all that apply)?
Trouble paying attention
Moves about constantly
Takes meds to calm him/her
Please tell us more about the child's hyperactivity.
What makes the child hyperactive or fidgety and what helps this behavior?
How would you describe the child's attention span?
Terrific attention span
Sometimes needs redirecting
Attention constantly needs redirecting
Very short attention span
Please let us know if there are any learning difficulties:
ie: Hearing impairment, Vision impairment, Dyslexia or reading difficulties. If there are any learning difficulties that will affect this camper's week or if there is information that would help us make camp better for your child please explain.
How often does the child lie?
ie: Never lies, Rarely lies, Frequently lies, Always lies, Can't tell lies from the truth
Please let us know how often this child runs away from a situation or from home?
Never runs away, Rarely runs away, Frequently runs away, Always runs away. Please explain what may trigger this behavior
Please let us know if -or how- the child may act out sexually?
Does not act out sexually
Touches other children
Makes inappropriate sexual comments
Flirts or pays inappropriate attention to others
Please explain what may trigger the sexual acting out
Please explain what may trigger this behavior and what helps in managing it.
How often does this child steal things?
ie: Never steals, Rarely steals, Frequently steals, Always steals, Know of stealing in the past, but not currently
How often does the child have tantrums or 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 and what may trigger the tantrums and/or anger issues?
How often and what may trigger this behavio? What helps calm the child down?
How often does this child withdraws?
How often and what may trigger this behavior? What helps the child to not withdraw?
How does this child rate on the Autistic scale:
Does not have signs of autisim
Explain the child's communication skills:
ie: Great listener, very expressive, likes to talk a lot, very quite, communication difficulties, lack of interest in other people, lack of eye contact, difficulty in understanding other people's feelings and expressing their own, limited response to social interaction
Any additional behavior information you need for our staff or counselors to know while your child is at camp?
Check all the boxes that are true about the child.
Does the child create a lot of noise?
Does the child crave bright lights, colors or busy pictures?
Does the child like to crash and bump into people, walls, etc.?
Does the child use a lot of force when touching, hugging, or with high fives?
Does the child stomp feet when walking or kick feet when sitting?
Does the child like to be under heavy blankets to sleep?
Does the child love to spin or swing?
Does the child like to hang upside down?
Is the child unaware of messiness on hands or face?
Does the child like to get dirty?
Does the child like bare feet?
Does the child dislike heavy backpacks or heavy blankets?
Does the child become very upset when bumped or pushed, even by accident?
Does the child dislike spinning or doing sumersaults?
Does the child get dizzy easily?
Does the child dislike being upside down?
Does the child dislike being picked up or moved?
Does the child dislike when his/her feet leave the ground?
Does the child wipe kisses off checks?
Does the child dislike tags in clothing, seams in socks, etc.?
Is the child sensitive to certain types of fabrics in clothing and/or sheets?
None of these apply
Medical History + Medication Information
Physicians Phone #
Childs medicaid/insurance number
Is child current on vaccinations?
Illnesses and Medical Complications Past or Present (check all that apply)
Topical Allergies (lotion, sunscreen, etc.)
Dizzy Spells and/or Fainting
ADD or ADHD
Heart or Circulation Problems
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 Broken Bones
List all known allergies to food, plants, medications, animals, etc.
Please explain any and all medical issue we should be aware of.
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 camper may not attend camp.
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
Pepto Bismal liquid and chewables
Calamine or Caladryl Lotion
Bactine (first aid/antiseptic/pain reliever)
Will your child be bringing Prescription and/or Over-the-Counter Medications?
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. IMPORTANT: All Medications must be in original container with pharmace or over the counter label on it. DO NOT pack medication in luggage, you will turn it into the nurse at registration.
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.
Prescription and/or Over-the-Counter medication 1
Name of medication
How long has child been taking this medication 1?
Reason for taking Prescription and/or over-the counter medication 1
Prescription and/or Over-the-Counter medication 2
Name of medication
How long has child been taking this medication 2?
Reason for taking Prescription and/or over-the counter medication 2
Prescription and/or Over-the-Counter medication 3
Name of medication
How long has child been taking this medication 3?
Reason for taking Prescription and/or over-the counter medication 3
Prescription and/or Over-the-Counter medication 4
Name of medication
How long has child been taking this medication 4?
Reason for taking Prescription and/or over-the counter medication 4
Any additional information we need to know about any prescription drugs, vitamins, or over-the-counter medications sent to camp - or - additional meds if any.
What specific activities should we ENCOURAGE your child to do while at camp?
What specific activities should be DISCOURAGED for medical reasons while at camp?
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 color...whatever!)
Please let us know strengths and great, positive things about this child. Please write as much as you'd like!
What does he or she do well? Good, positive traits and characteristics? Things in which you can be proud of this child?
How did you hear about Royal Family KIDS Camp
Stay Connected through our Mentoring Club
Mentoring Club is designed for any child that has attended Royal Family KIDS Camp
Throughout the school year campers and their mentors attend a once a month mentoring club meeting. Mentoring club is a place where a camper can reconnect with many of the participating staff members from camp as well as build lasting friendships with the other mentoring club kids. Club KIDS enjoy the same songs, games, and friends they met at Camp, which reinforces stability and character strength in their lives. Are you interested in finding out how this child can be part of the RFK Club & Mentors Program throughout the 2023-2024 school year?
Yes - Please register the child for mentoring.
Maybe - Please send me more information!
No, thank you
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 Mountain View Christian Assembly of God, For The Children, and Royal Family Kids Camp from all and any liability. Sign by using your mouse pad or touch screen.
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