RFK Mentoring Child Application

Royal Family KIDS Mentoring

For Foster Kids | 7 - 11 Years Old

January to June 2024

For information, contact:
Child Placement Coordinator, Laura Torres-Camarillo
venturarfkc@gmail.com

Sponsored by
Ventura Missionary Church
500 High Point Drive, Ventura, CA 93003
PROGRAM 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 rerturned 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 this wonderful program!
Camper Information
Child's Full Name*

First NameMiddle NameLast Name
Nickname or Preferred Name
Sex*

MaleFemale
Birthdate*
mm/dd/yyyy
Child's Age*
Current Emotional Age*
Grade in fall 2024*
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

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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 mentoring 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:
Child's Details
Tell us about the child! Share any information you think we should know to help the child have a wonderful time at Mentoring.
My child enjoys:

SportsSwimmingHiking & NatureArts & CraftsMusicSingingDancingActing/PerformingWoodworkingAnimalsReading/StudyingOther
Reading Level*
Learning Disabilities*

YesNo
How did you learn about Royal Family Kids Mentoring?*
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 child's latest vaccination record (max file size 2048 kb)*

Upload a File

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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?
Disabilities/Limitations
Including leg or arm braces, hearing aids, etc.
Please add any other comments related to HEALTH and MEDICATIONS
ACKNOWLEDGEMENTS and RELEASES

PLEASE NO CAMERAS, SMART WATCHES, TABLETS, ELECTRONIC GAMES, PHONES, OR MONEY. THESE ITEMS ARE NOT NEEDED AT CAMP.
I hereby give permission for my child to attend and participate in Royal Family Kids Mentoring 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 Mentoring 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 MentorRFKCVTA@gmail.com
Should be Empty:

PROGRAM REGISTRATION FORM

Camper Information

EMOTIONAL & BEHAVIORAL HISTORY

Child's Details

HEALTH HISTORY

ACKNOWLEDGEMENTS and RELEASES

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