RFKC-MV 2023 Camper Application

REGISTRATION FORM

Royal Family KIDS Camp is a program of For The Children - Sponsored by Mission Viejo Christian Church, 27192 Jeronimo Rd. Mission Viejo, CA 92692 July 1 - July 5, 2024
About the Child - This form should be completed by the caseworker/social worker and/or the foster parent(s). Instructions: his form must be completely filled out. The information is vital to the health and wellbeing of the child. Your application will be returned to you if it is not completely filled in. 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.
Full Legal Name of Camper*

First NameMiddle NameLast Name
Preferred Name/Nickname of Camper
Gender of Camper*

MaleFemale
Age of Camper: *
Date of Birth: *

MonthDayYear
Date
Estimate of Developmental Age of Camper
Upload picture of Camper here if available*

Upload a File

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Choose all that apply:*

This is Campers first time at Royal Family KIDS CampCamper has been to camp beforeCamper has siblings coming to camp
Child is currently living with: *

Foster ParentRelativeGroup HomeOther
(Primary) Name of Person Child is Living With: *

First NameMiddle NameLast Name
Best phone number to to contact primary caregiver*

Area CodePhone Number
(Secondary) Name of Person Child is Living With:

First NameMiddle NameLast Name
Best phone number to to contact secondary caregiver

Area CodePhone Number
Address Where Child is Living: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail of Primary Contact:*

Confirmation Email
Social Worker/Case Worker Name: *

First NameMiddle NameLast Name
SOCIAL WORKER/CASE WORKER Phone Number: *

Area CodePhone Number
SOCIAL WOKER/CASE WORKER EMAIL: *

Confirmation Emailexample@example.com
CHILD Emergency Contact*

First NameMiddle NameLast Name
Relationship (of Emergency Contact)*
Phone Number (of Emergency Contact) *

Area CodePhone Number
Child T-Shirt Size*

Child SmallChild MediumChild LargeChild XLAdult SmallAdult MediumAdult LargeAdult XL
Childs History
Number of known placements for foster child (including current placement)
Does child have current visitations with biological parent(s)

YesNoUnknown
Please mark all that apply to child's current emotional or behavioral concerns: (The camp Child Specialist will reach out prior to camp to discuss items marked to give the camper the best possible experience at camp).

AggressiveBitingBedwettingEating disordersLearning delays or disabilitiesHyperactiveSpeech DelaysNight Terrors, Nightmares, Frequently awakes in the nightStealsFrequently lies or exaggerates reality (dramatic)Runs awayTantrums or physical outburstsSexually acting outActs much more mature than their ageActs much more immature than their ageAudio (hearing) sensory issuesTactile (touch) sensory issuesLikes to spin, jump or be constantly movingWiggles or fidgets when trying to sit stillHas difficulty following directionsWithdraws or gets quiet when upsetHas emotional or physical outbursts when upsetHides or hoards food or other itemsDifficulty swallowing or chokes frequentlyClumsy, falls or crashes into things oftenNeeds to fidget or draw while listeningChews or bites nails excessively
Other concerns that I would like to discuss with the camp Child Specialist/Licensed Counselor prior to camp:
Has the camper been the victim of sexual abuse? *

YesNoUnknown
Has the camper been the victim of physical abuse? *

YesNoUnknown
How long has the child been in the care of their present placement? *
Camper Details
Please tell us a little about your camper. (This helps us encourage enjoyable and confident participation in activities at camp).

Likes to swimLikes musicLikes to draw or is artistic and creativeLikes sportsLikes animalsLikes to fish or wants to tryMakes friend easilyNeeds help making friendsLikes to try new thingsNeeds help trying new thingsIs very active and energeticIs less active and prefers to do things that are more quiet and reservedLikes to build things (legos, wood projects, etc.)Likes to readHas a funny sense of humor or is wittyIs very helpful and likes to help othersIs very neat and tidyIs more slopp/messy - has a hard time keeping track of things or loses things easilyIs a great eater (different than unhealthy over eating)Is a picky eaterPrefers smaller groups and one on one activitiesLikes big groups and noise and activityLikes to act or be involved in plays/dramaIs a great story teller (different than lying)Can shower and bathe without assistancePrefers total darkness at night when sleepingNeeds some assistant bathing, washing hair etc. (note: the child is never alone at camp with another child or an adult - we do have alternative methods of helping a child shower/bathe with supervised assistance to their needs)Is afraid of the dark at night
Other characteristics unique to this child you'd like us to know:
Health & Medical History
Please mark all that apply:

Child has leg or arm bracesDiagnosed eating disorderHeart conditionHypoglycemiaBack injury or bracesDiabetesSeizuresHearing aids or hearing impairmentRespiratory or breathing problemsPulmonary EdemaFainting or dizzy spellsAnaphylactic shockFoot/feet braces or surgeriesBalance problemsSkin issues/rashes/lesions/bruises easily
Are any activities to be restricted?
Does the child have any of the following known allergies?

BeesOther insect allergiesSeasonal (please list below)Food allergies (please list below)Dairy allergiesDrug allergies (please list below)Gluten (please indicate sensitivity or diagnosed celiac)Other
Please detail above allergies or describe "other":
Does your child need to have close access to an Epi pen?
Does the camper have asthma?

YesNoThe camper has an inhaler that will be sent to camp with them.
Prescription Medications
Does the child take any medications? *

YesNo
Please list all medications, dosage & reason for taking.

Medication NameDosage Diagnosis or Reason for taking
Medication NameDosage Diagnosis or Reason for taking
Medication NameDosage Diagnosis or Reason for taking
Medication NameDosage Diagnosis or Reason for taking
Medication NameDosage Diagnosis or Reason for taking
Prescribing or Primary Doctor's Name*

First Name Middle Name Last Name
Doctor Phone Number*

Area CodePhone Number
Has the child had any serious illness, injuries, or medical operations in the last three years?*

YesNo
Please list illness or operations:
Insurance Card Number*
Are all immunizations current for the camper? *

NoYesUnknown
Upload immunization card*

Browse Files

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Other medical conditions we need to know about the camper:
Authorized Person(s) to Pick Up Child:

Authorized person(s) will need to show identification and be cleared with Social Worker/Case Workers to pick up child. Children will NOT be released to unauthorized or previously cleared person(s). PLEASE ARRIVE AT PICK UP LOCATION (the pick up location, date, and time to be announced)
Person Authorized to Pick Up Child: *

First Name Middle Name Last Name
Phone Number*

Area CodePhone Number
Person Authorized to Pick Up Child:

First Name Middle Name Last Name
Phone Number

Area CodePhone Number
Person Authorized to Pick Up Child:

First Name Middle Name Last Name
Phone Number

Area CodePhone Number
Medical Authorization and Release:

Must be signed by Case Worker/Social Worker or Legal Guardian
Printed Name of Legal Guardian/ Caseworker or Social Worker *

First NameLast Name
Signature of Legal Guardian/ Caseworker or Social Worker *

Clear
We look forward to spending time with your child at CAMP!

Please don't hesitate to reach out with any questions about Camp or the above application.
Should be Empty:

REGISTRATION FORM

Childs History

Camper Details

Health & Medical History

Prescription Medications

Authorized Person(s) to Pick Up Child:

Medical Authorization and Release:

We look forward to spending time with your child at CAMP!