2024 Ventura RFK Camper Application

Royal Family KIDS Camp

For Foster Kids | 7 - 11 Years Old

July 1 - 5, 2024

For information, contact:
Child Placement Coordinator,
/ VenturaRFKC@gmail.com

Sponsored by
Ventura Missionary Church
500 High Point Drive, Ventura, CA 93003
CAMPER REGISTRATION FORM
Instructions: This form must be completely filled out. The information is vital to the health and well being of the child. Your application will be terturned to you if it is not completely filled in. Before you begin, please ensure that you have the following:
1. A "selfie" or face picture of the child
2. A scan of the child's immunization records to upload
3. A photo of the child's Medi-care, Medi-cal, or private insurance card
Thank you for joining us for a wonderful week of camp!
Camper Information
Child's Full Name*

First NameMiddle NameLast Name
Nickname or Preferred Name
Sex*

MaleFemale
Birthdate*
mm/dd/yyyy
Camper's Age*
Current Emotional Age*
Grade in fall 2022*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload a current headshot photo of the child here:*

Upload a File

Cancelof
The child is living with: (Check one)*

Foster ParentGroup HomeRelativeOther
Name(s) and relationship(s) of the person(s) the child is living with*
Preferred Phone #*

Area CodePhone Number
Alternate Phone #

Area CodePhone Number
E-mail*

Confirmation Emailexample@example.com
Emergency Contact Name*
Relationship to child*
Emergency Phone #*

Area CodePhone Number
Alternate Emergency Phone #

Area CodePhone Number
County Social Worker's Name
County Social Worker's Phone #

Area CodePhone Number
County Social Worker's E-mail

Confirmation Emailexample@example.com
Foster Agency Social Worker's Name
Foster Agency Social Worker's Phone #

Area CodePhone Number
Foster Agency Social Worker's E-mail

Confirmation Emailexample@example.com
Moved in Foster Placement how many times?*
Explain any unusual family circumstances that make camp especially important for the child: (for example: recent crisis, being moved in foster placement, severe economic needs, etc.)
EMOTIONAL & BEHAVIORAL HISTORY

Please answer if your child displays any of the following behaviors, and explain below for any for which you answered SOMETIMES OR OFTEN.*

	Not at all	Some- times	Often
Aggressiveness
Bedwetting
Biting
Eating Disorder
Hoarding Food
Hyperactivity
Learning Disability
Lying
Nightmares
Night Terrors
Runs Away
Sexual Acting Out
Stealing
Tantrums
Violent
Withdrawn

If you answered OFTEN or SOMETIMES to any of behavioral history above, please explain here:
Camper Details
Tell us about the child! Share any information you think we should know to help the child have an amazing week at camp.
My child enjoys:

SportsSwimmingHiking & NatureArts & CraftsMusicSingingDancingActing/PerformingWoodworkingAnimalsReading/StudyingOther
Are you aware of the child's swimming abilities?*

YesNo

Reading Level*
Learning Disabilities*

YesNo
Has the child attended a Royal Family Kids Camp before?*

YesNo
If yes, where?
How did you learn about Royal Family Kids Camp?*
Child's religious or faith background, if known
Camper's T-Shirt Size:*

Child SmallChild MediumChild LargeAdult SmallAdult MediumAdult Large
HEALTH HISTORY

Indicate all known allergies, illness, disabilities, physical limitations, or medical complications
Child's Doctor's Name & Phone #*
Upload a clear scan of the camper's latest vaccination record (max file size 2048 kb)*

Upload a File

Cancelof
Please upload a clear photo of the child's medical insurance card:*

Upload a File

Cancelof
Child's Medicare, Medi-Cal or Private Insurance Co. & Policy #

Has your child had any of the following conditions? If YES, please explain below.*

	Yes	No
Allergies
Serious Illness or Operation
Anaphylactic Reactions
Insect Bite Reactions
Poison Oak Reactions
Asthma / Respiratory Issues
Hay Fever
Balance Issues or Dizzy Spells
Fainting
Diabetes
Pulmonary Edema
Seizure Disorder
Heart or Circulatory Issues
Back, Bone, or Muscle Injury
Drug Allergy
Sleep Disorder
Disability/Limitations
Other Problems or Restrictions
Hypoglycemia

If you checked YES for any of the above medical issues, please explain here including WHEN, the REACTION or COMPLICATION, the SEVERITY, and any RESIDUAL IMPAIRMENT for each condition for which you answered YES.
Are there any specific activities that should be encouraged or restricted?
Eating Disorder*

YesNo
Disabilities/Limitations
Including leg or arm braces, hearing aids, etc.
Is your child taking any medication(s)?*

YesNo
Royal Family Kids Camp is an overnight camp, over 5 days and 4 nights. If your child will need any medications during camp, please list below.
Medication #1 Name
Medication #1 for what condition?
Medication #1 Dosage
Medication #1 Times
Does your child take any other medication(s)?

YesNo
Medication #2 Name
Medication #2 for what condition?
Medication #2 Dosage
Medication #2 Times
Does your child take any other medication(s)?

YesNo
Medication #3 Name
Medication #3 for what condition?
Medication #3 Dosage
Medication #3 Times
Does your child take any other medication(s)?

YesNo
Medication #4 Name
Medication #4 for what condition?
Medication #4 Dosage
Medication #4 Times
Does your child take any other medication(s)?

YesNo
Medication #5 Name
Medication #5 for what condition?
Medication #5 Dosage
Medication #5 Times
Does your child take any other medication(s)?

YesNo
Medication #6 Name
Medication #6 for what condition?
Medication #6 Dosage
Medication #6 Times
Does your child take any other medication(s)?

YesNo
Medication #7 Name
Medication #7 for what condition?
Medication #7 Dosage
Medication #7 Times
Does your child take any other medication(s)?

YesNo
Medication #8 Name
Medication #8 for what condition?
Medication #8 Dosage
Medication #8 Times
Does your child have any or special dietary needs or restrictions?*

YesNo
Please explain
Please add any other comments related to HEALTH and MEDICATIONS
I understand that it is my responsibility as caregiver to make sure that all instructions are clear and that the necessary dosage is adequately supplied for the duration of camp. I hereby authorize RFKC's nurse to administer the above medication from July 1 - July 5, 2023.*

Clear
ACKNOWLEDGEMENTS and RELEASES

PLEASE NO CAMERAS, SMART WATCHES, TABLETS, ELECTRONIC GAMES, PHONES, OR MONEY. THESE ITEMS ARE NOT NEEDED AT CAMP.

Please check YES or NO for each medication/remedy listed below. This form must be completed by the child's primary caregiver in order for the child to attend camp. *

	Yes	No
Sunblock
Insect repellant
Lip balm
Rash ointment
Tylenol
Ibuprofen
Antiseptic ointment
Bandages
Anti-itch cream
Hydrogen peroxide
Cough syrup
Cough drops
Decongestant
Antihistamine
TUMS
Pepto Bismol
Anti-lice treatment/shampoo

I hereby give permission for my child to attend and participate in Royal Family Kids Camp of Ventura Missionary Church. (Signature of parent/guardian)*

Clear
Type your name*
Relationship to minor*
Today's Date:*

MonthDayYear
Date
Person(s) Authorized to pick-up child*
Phone Number*

Area CodePhone Number
Thank you for your submitting to register your child for Royal Family Kids Camp of Ventura.

Please check your e-mail for further instructions or information. In the meantime, if you have any questions, please contact , Child Placement Coordinator, at: or VenturaRFKC@gmail.com
Should be Empty:

CAMPER REGISTRATION FORM

Camper Information

EMOTIONAL & BEHAVIORAL HISTORY

Camper Details

HEALTH HISTORY

ACKNOWLEDGEMENTS and RELEASES

Thank you for your submitting to register your child for Royal Family Kids Camp of Ventura.