RFKC SBC Camper Application 2024

Royal Family Kids' Camp June 10-14, 2024

with Scottsdale Bible Church
This application must be filled out and submitted online and will likely take 30 minutes to complete.

Your child's photo and medical insurance card can be uploaded with this application or submitted separately to carolmoench@azroyalfamily.com

All campers must be between the ages of 7 - 11 at the time of camp:
June 10-14, 2024.

NOTE: If you have an older child or these dates do not work for you, please visit azhope.com/camps for more camp dates. Please register a child for ONLY one RFKC per summer.

Drop-off / Pick-up location:

Scottsdale Bible Church
7601 E. Shea Blvd, Scottsdale, AZ 85260

If you have questions or concerns about RFKC Scottsdale, please contact your child placement coordinator or Carol Moench at carolmoench@azroyalfamily.com.
Name of Person Filling Out This Application*

First NameLast Name
Relationship To Child*

CaseworkerGuardianOther
Child's Information
Child's Name*

First NameLast Name
Preferred Name (if child has one)
If child is a returning Royal Family KIDS camper and had a DIFFERENT NAME LAST year, please let us know!

First NameLast Name
Gender*

MaleFemale
Birthdate*

MonthDayYear
Age at Time of Camp (June 10, 2024)*

6 years old7 years old8 years old9 years old10 years old11 years old12 years old
Emotional Age *
This child will be entering this grade in the fall of 2024.*

1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade
Child's T-Shirt Size (shirts run small)*

Child MediumChild LargeAdult MediumAdult LargeAdult XL
Is this child a returning RFK Camper?*

Yes, returning RFK CamperNo, not a returning RFK CamperDon't know if child has been to RFKC before
Siblings of Child Applying to RFKC This Summer

Please note that in addition to listing each sibling below a separate application for each is child is needed
If a sibling of this child is applying to camp, please tell us who that is.

First NameLast Name
This sibling is a...

Biological SiblingFoster SiblingSibling in Adoptive Family
If 2nd sibling is applying to camp, please tell us who that is.

First NameLast Name
2nd sibling is a...

Biological SiblingFoster SiblingSibling in Adoptive Family
If 3rd sibling is applying to camp, please tell us who that is.

First NameLast Name
3rd sibling is a...

Biological SiblingFoster SiblingSibling in Adoptive Family
If 4th sibling is applying to camp, please tell us who that is.

First NameLast Name
4th sibling is a...

Biological SiblingFoster SiblingSibling in Adoptive Family
Parent/Guardian Information
At time of camp, how long will this child have been living in current home?*

less than 4 months4-6 months6-11 months1-2 years2-3 years3-4 years4+ yearsOther
This home is best described as...*

Foster HomeAdoptive ParentsGroup HomeKinshipBiological Parent(s)Other
Total # foster or residential placements for child including current home:
Home Mailing Address (for camp correspondence)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent or Legal Guardian #1 (this person will receive the email auto reply and future email correspondence regarding child) *

First NameLast Name
Relationship to Child*
Best Phone Number*

Area CodePhone Number
This phone is a:*

Cell PhoneWork PhoneHome Phone (land line)
Parent/Guardian #1 Email Address*
Parent or Legal Guardian #2

First NameLast Name
Relationship to Child
Parent or Legal Guardian #2 Best Phone Number

Area CodePhone Number
This phone is a:

Cell PhoneWork PhoneHome Phone (land line)
Parent/Guardian #2 Email Address
Authorized to Pick Child Up From Camp on Friday, June 14th
Who is an authorized adult that may pick this child up after camp June 14, 2024? **Government ID required***

First NameLast Name
Cell Number for Authorized Adult *

Area CodePhone Number
SECOND authorized adult. **Government ID required**

First NameLast Name
Cell Number For Authorized Adult

Area CodePhone Number
Caseworker/Child Placement Agency Information
Caseworker Name*

First NameLast Name
Caseworker Email*
Caseworker Phone 1*

Area CodePhone Number
Caseworker Phone 2

Area CodePhone Number
Caseworker's Supervisor

First NameLast Name
Supervisor Email
Supervisor Phone Number (not intake #)*

Area CodePhone Number
Background/Behavior Information

Please fill this out to the best of your ability. All information shared is confidential. We as RFKC staff want to make sure this child as well as other campers have a safe, healthy, fun time at camp. This information is extremely helpful and is only shared with camp staff on a "need to know" basis.
Why would this child's attendance at RFKC be important? Why would you like to see him or her attend camp?*
How often does this child wet the bed at night?*

Never wets the bedRarely wets the bedFrequently wets the bedWets the bed every nightDo not know about bed wetting
If child does wet the bed, please explain (i.e. wears pull-ups, don't drink liquids after certain time, just need to be aware, etc.)
Does this child display aggressive behavior?*

Never aggressiveRarely aggressiveFrequently aggressiveAlways AggressiveDo not know if child is aggressive
Please explain aggressive behavior. (What may trigger aggressive behavior or to whom child is aggressive.)
Does the child deal with any of the following eating disorders or issues around food?*

AnorexiaBulimiaOvereating/GorgingNo Eating DisordersDo Not Know Of Any Eating DisordersHording or Stealing FoodOther
If this child does have an eating disorder - or has other issues around food we should know about - please explain.
How would you describe this child's demeanor?*

Very calmSomewhat hyperactiveFrequently hyperactiveAlways hyperactiveDon't know about hyperactivity
Please let us know if any of the following learning difficulties exist for this child.

Hearing impairmentVision impairment (that would affect time at camp)Reading difficultiesDon't know about learning difficultiesOther
How often does this child lie?*

Never liesRarely liesFrequently liesAlways liesCan't tell lies from truthDon't know if this child has a habit of lying
Please let us know how often this child has night terrors.*

No night terrorsRarely has night terrorsFrequently has night terrorsDon't yet know about night terrors
Please let us know how to calm this child or prevent nightmares.
Please let us know how often this child has nightmares.*

No nightmaresRarely has nightmaresFrequently has nightmaresDon't yet know about nightmares
Please let us know how often this child runs away from a situation or from home.*

Never runs awayRarely runs awayFrequently runs awayAlways runs awayDon't yet know if child runs away
Please let us know if - or how - this child may act out sexually.*

Does not act out sexuallyDo not know if sexually acts outTouches selfTouches other childrenFlirts or pays inappropriate attention to adults
How often does this child steal things?*

Never stealsRarely stealsFrequently stealsDo not know about stealing yetKnow of stealing in the past, but not currently
If this child does act out sexually, please explain.
How often does this child have tantrums or anger issues?*

Does not have tantrums or anger issuesRarely has tantrums or anger issuesFrequently has tantrums or anger issuesDon't know about tantrums or anger yet.
If this child does have tantrums or anger issues that are beyond normal childhood frustrations, please explain so we know how to redirect or prevent outbursts.
How often does this child withdraw?*

Never withdrawnRarely withdrawnFrequently withdrawnDon't know about how often child withdraws yet
HISTORY/STORY: Please share this child's history or story so we can understand how to give him or her an even MORE amazing week at camp!
** Please tell us about this child's history or story. What situations may have been challenging for this child before living in your home? What circumstances is this child dealing with?*
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 tell us what this child's interests, passions, loves, etc. are so our Staff can make camp even more special! (i.e. Loves sports, interested in horses, favorite color is purple...whatever!)
Medical History + Prescription Medication Information
List ALL known ALLERGIES to food, plants, medications, animals, etc.*
Illnesses and Medical Complications Past or Present (check all that apply)*

Respiratory ProblemsSeasonal AllergiesFood AllergiesMedicine AllergiesTopical Allergies (lotion, sunscreen, etc.)Dizzy Spells and/or FaintingSeizure DisordersAnaphylactic ShockBalance ProblemsAsthmaADD or ADHDHypoglycemiaHeart or Circulation ProblemsType 1 DiabetesType 2 DiabetesInsect Bite Allergies (i.e. mosquitoes, bees, etc.)Recent SurgeryRecent Broken BonesNONEOther
This child's swimming ability is...*

Poor Swimming AbilityGood Swimming AbilityExcellent Swimming AbilityDo Not Know Swimming Ability
Please explain each medical issue you checked above. (If you did not check anything, please say DOES NOT APPLY."*
What, if any, specific activities should be DISCOURAGED for medical reasons while at camp?
Date of last TDap (tetanus) shot:
Non-Prescription/Over-The-Counter Medications

(ex: tylenol, ibuprofen/motrin, benadryl, etc.)
NON-PRESCRIPTION Medications / Treatments Release:*

Please check here if ALL NON-PRESCRIPTION AND OVER-THE-COUNTER TREATMENTS ARE ALLOWED TO BE GIVEN TO THE CHILD WHILE AT CAMPCheck here if there are EXCEPTIONS for non-prescription medications/over-the-counter for your camper to NOT receive at camp (please type below):
Non-Prescription/Over-The-Counter Medications Camper should NOT receive (if applicable):
Prescription Medications

Please include ALL prescribed or over-the-counter medications, vitamins, and/or inhalers that your child takes routinely at home. If not applicable, leave blank.
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 (Monday June 10th- Friday, June 14, 2024.) I authorize RFKC medical staff to administer the medications.*

Yes, I understand that sharing medical info, medications, and dosages are my responsibility.
Prescription or Over-the-Counter Medication #1
Prescription Medication 1: Reason for taking, DOSAGE, and Time(s) of Day to Administer
How long has child been taking Medication #1? (Be specific.)
Prescription or Over-the-Counter Medication #2
Medication 2: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
How long has child been taking Medication #2? (Be specific.)
Prescription or Over-the-Counter Medication #3
Medication 3: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
How long as child been taking Medication #3? (Be specific.)
Prescription or Over-the-Counter Medication #4
Medication #4: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
How long as child been taking Medication #4? (Be specific.)
Prescription or Over-the-Counter Medication #5
Medication #5: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
How long has child been taking Medication #5? (Be specific.)
Additional information we need to know about the above prescription drugs, vitamins, or over-the-counter medications sent to camp - or - additional medications, if any.
Primary Doctor*

First NameLast Name
Doctor's Phone Number*

Area CodePhone Number
Please upload a recent photo of this child. Upload a JPG ONLY...do NOT upload a PDF or other file type **. You will not be able to upload a photo larger than 1 MB (or 1024 KB) in size.

Upload a File

Cancelof
Please upload a photo of the child's medical insurance card. Upload a JPG ONLY...do NOT upload a PDF or other file type **. You will not be able to upload a photo larger than 1 MB (or 1024 KB) in size.

Upload a File

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EMERGENCY MEDICAL RELEASE:

This health history is correct so far as I know, and the above named minor has permission to engage in all prescribed program activities, except as noted. The undersigned do hereby authorize the directors of Royal Family KIDS Camp, or such substitute as they may designate, as agent for the undersigned to consent to: X-Ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care for the above minor, which deemed advisable by, and to be rendered under the general or special supervision of any physician and surgeon, licensed under the provision of the Medicine Practice Act or any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, camp or elsewhere. I release this minor to be transported by camp staff as needed for emergent medical attention by private vehicle if deemed necessary by camp medical staff. This authorization will remain effective while the above minor is en-route to and from camp, involved or participating in any camp program, unless revoked in writing by the undersigned and delivered to the Director of Royal Family as legal guardian/social worker/other. My permission is given for the minor named in this application to attend Royal Family KIDS Camp in the summer of 2024 through Scottsdale Bible Church, 7601 E. Shea Blvd, Scottsdale, AZ 85260.
PERMISSION TO TRANSPORT:

The above-mentioned organizations, are hereby authorized to transport said minor by bus from the registration location in Scottsdale, AZ to the campground on Monday June 10th, 2024, and transport the minor from the campground to the pick-up location in Scottsdale, AZ on Friday, June 14th, 2024. I understand that if I should, for any reason, desire to retrieve said minor from camp before Friday, June 14th, 2024, I will first be required to make arrangements with the directors and meet at an agreed upon location. By my signature, I release Scottsdale Bible Church, Royal Family Kids inc, and any other involved parties from liability in relation to travel to and from camp. In the event of an emergency, I consent to emergency services as deemed necessary by medical professionals to transport the minor to and from medical facilities. I also give permission for this minor to be transported by bus to and from water activities during camp schedule or a private vehicle for emergencies if deemed necessary by camp staff.
I consent to emergency medical release and permission to transport as written above:*

First NameLast Name
Enter the message as it's shown*
Email
example@example.com
Should be Empty:

Royal Family Kids' Camp June 10-14, 2024

Child's Information

Siblings of Child Applying to RFKC This Summer

Parent/Guardian Information

Authorized to Pick Child Up From Camp on Friday, June 14th

Caseworker/Child Placement Agency Information

Background/Behavior Information

HISTORY/STORY: Please share this child's history or story so we can understand how to give him or her an even MORE amazing week at camp!

Medical History + Prescription Medication Information

Non-Prescription/Over-The-Counter Medications

Prescription Medications

EMERGENCY MEDICAL RELEASE:

PERMISSION TO TRANSPORT: