RFK Camp and Mentoring Application (kids)

IF YOU HAVE QUESTIONS about this application, about required paperwork, other need assistance: Please contact Sharon Callahan or Gail Watkins @ ftctuscaloosa@gmail.com
Name of Person Filling Out This Application*

First NameLast Name
Relationship To Child*

CaseworkerFoster ParentAdoptive ParentBiological ParentRelativeOther
Child's Information
Child's Name*

First NameLast Name
Preferred Name (if child has one)*
Gender*

MaleFemale
Birthdate*

MonthDayYear
Grade in school:*

Kindergarten1st grade2nd grade3rd grade4th grade5th grade
Actual Age*
Maturity Level*

ImmatureAct their AgeMature
Is this child a returning RFK Camper or from RFK Group Mentoring?*

Yes, returning RFK Group MentoringYes, returning RFK CamperNo, not a returning RFK Camper
If yes, what year, city, and state?
Child's T-Shirt Size*

Youth SmallYouth MediumYouth LargeAdult MediumAdult LargeAdult Extra Large
Siblings of Child Applying to RFK Camp/Mentoring

If siblings of this child will ALSO be applying to the FTC Tuscaloosa RFK Camp/Mentoring program, please provide their information as well. (Please note that you will need to complete a separate application for each child.)
If a sibling of this child is applying to RFK Camp/Mentoring, 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/mentoring, 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/mentoring, 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/mentoring, please tell us who that is.

First NameLast Name
4th sibling is a...

Biological SiblingFoster SiblingSibling in Adoptive Family
Parent/Guardian Information
This home is best described as...*

Foster HomeAdoptive ParentsGroup HomeResidential TreatmentRelativeBiological Parent(s)Other
If this child was adopted, when did you adopt him or her?

MonthDayYear
At time of camp/mentoring, how long will this child have been living in current home?*

1 month2 months3 months4-6 months6-11 months1-2 years2-3 years3-4 years4+ yearsOther
Approximately when was this child placed in the current home?*

MonthDayYear
Total # foster or residential placements for child including current home.*
Mailing Address (for correspondence)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent or Legal Guardian #1*

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 Two Email Address
Authorized to Pick Child Up at Valley View Baptist at the end of RFK Mentoring each month or the end of camp week.
Authorized adult that will be picking this child up from VVBC after RFK Camp/Mentoring each month. **Government ID required***

First NameLast Name
Cell Number for Authorized Adult #1*

Area CodePhone Number
SECOND adult authorized to pick up this child from VVBC after RFK Camp/Mentoring each month. **Government ID required**

First NameLast Name
Cell Number For Authorized Adult #2

Area CodePhone Number
Caseworker/Child Placement Agency Information
Child Placement Agency (Current or Past if Child Has Been Adopted)*
Caseworker Name*

First NameLast Name
Caseworker Email*
Caseworker Phone 1*

Area CodePhone Number
Caseworker Phone 2

Area CodePhone Number
CASA (Court Appointed Special Advocate) if child has one

First NameLast Name
CASA Email
CASA Phone Number

Area CodePhone Number
Background/Behavior Information

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/mentoring. This information is extremely helpful!
Why would this child's attendance at RFK Camp/Group Mentoring be important? Why would you like to see him or her attend?*
How often does this child have bathroom accidents?*

NeverRarelyFrequentlyDo not know
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 this child bite other children or adults?*

Do Not Know About Biting OthersNever Bites OthersRarely Bites OthersFrequently Bites Others
Does the child deal with any of the following eating disorders or issues around food?*

AnorexiaBulemiaOvereating/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 often has this child start (non-campfire) fires?*

Don't know about fire-starting habitsDoes not start firesStarted a few fires in the pastStarted many fires in the past
If this child has set fires, please explain.
How would you describe this child's hyperactivity?*

Very calmSomewhat hyperactiveFrequently hyperactiveAlways hyperactiveDon't know about hyperactivity
How would you describe this attention span?*

Terrific attention spanAttention constantly needs redirectingDo know know about attention span yetVery short attention span
Please let us know if any of the following learning difficulties exist for this child.

Hearing impairmentVision impairmentDyslexia or reading difficultiesDon't know about learning difficultiesOther
If these learning difficulties will negatively affect this camper's week at camp/mentoring - or if this information would help Staff make camp/mentoring better for your child - please explain.
How often does your child lie?*

Never liesRarely liesFrequently liesAlways liesCan't tell lies from truthDon't know if this child has a habit of lying
If this child does have a habit of lying, please explain.
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
If this child does run away, please explain what calms him or her down or what triggers running 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
If this child does act out sexually, please explain.
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 steal or take things, 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
If this child is withdrawn (or certain circumstances cause this), please explain.
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 or mentoring time.
** 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 or Mentoring in the past, what did he or she like about it? What positive changes or behaviors did you see upon their return home?
Please let us know strengths and great, positive things about this child. Please write as much as you'd like!*
Please tell us what this child's interests, passions, loves, etc. are so our Staff can make camp/mentoring even more special! (i.e. Loves sports, interested in horses, favorite color is purple...whatever!)*
Any additional information you need for our staff or counselors to know while your child is up at camp/mentoring?
Medical History + Prescription Medication Information

Please send a copy of child's insurance/medicaid card to ftctuscaloosa@gmail.com
List all known allergies to food, plants, medications, animals, etc.*
This child's swimming ability is...*

Poor Swimming AbilityGood Swimming AbilityExcellent Swimming AbilityDo Not Know Swimming Ability
What specific activities should we encourage your child to try while at camp/mentoring?*
Illnesses and Medical Complications Past or Present (check all that apply)*

Respiratory ProblemsMuscuoskeletal AllergiesFood AllergiesMedicine AllergiesTopical Allergies (lotion, sunscreen, etc.)Dizzy Spells and/or FaintingFoot ProblemsBack ProblemsSeizure DisordersAnaphylactic ShockBalance ProblemsAsthmaADD or ADHDHypoglycemiaHeart or Circulation ProblemsPulmonary EdemaHay FeverPoison Oak/Poison Ivy AllergiesType 1 Diabetes (previously insulin-dependent)Type 2 Diabetes (previously non-insulin dependent)Insect Bite Allergies (i.e. mosquitoes, bees, wasps, etc.)Recent SurgeryRecent Broken BonesOther
Please explain each medical issue you checked above. (If you did not check anything, please say DOES NOT APPLY."*
What specific activities should be DISCOURAGED for medical reasons while at camp/mentoring?*
NON-APPROVED Medications / Treatments: Check ONLY those you DO NOT WANT the medical team to administer. Please refrain from the following...*

Sunblock/SunscreenInsect RepellantLip BalmRash OintmentTylenol or AdvilAntiseptic OintmentBandaidsAnti-Itch CreamHydrogen PeroxideRubbing AlcoholCough SyrupCough DropsDecongestantAntihistamineSwimmers ear/earache dropsEye drops (saline or antihistamine)Other
Please explain why you said NO to the medications you checked above. (If you did not check any, just say DOES NOT APPLY.)*
Prescription & Over-the-Counter Medications

If your child is NOT taking any prescription or over-the-counter medications, vitamins, or inhalers to camp/mentoring, please type "NONE" in each of the boxes.
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 week/mentoring time. I authorize RFKC medical staff to administer the medications.*

Yes, I understand that sharing medical info, medications, and dosages are my responsibility.No, I do not 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 as 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.)
If your child takes more than 5 medications each day, please list any other medications, reason, for taking, dosage, and time of day to administer.*
Additional information we need to know about the above prescription drugs, vitamins, or over-the-counter medications sent to camp/mentoring - or - additional meds if any.*
Physician, PA, or NP for Child*

First NameLast Name
Physician, PA, NP, or Clinic Phone Number*

Area CodePhone Number
Medical Release

This Medical Release Form is effective on the date of my signature(s) below, and will remain in full force and effect as long as my child participates with Royal Family KIDS Camp/Mentoring in any manner; it applies to all Camp/Mentoring activities, including group meetings, functions, and events (the “Activities”).I hereby give permission for my child to attend and participate in the Activities. I specifically authorize Royal Family KIDSCamp/Mentoring to provide for, and arrange in my place, necessary medical care.I authorize the Royal Family KIDS Camp and Mentoring Director or any designated adult, in whose care my child has been entrusted, to arrange for and consent to any x-ray examination, anesthetic, and/or medical, surgical and dental procedure and treatment, and hospital care, to be rendered to my child under the general or special supervision, and on the advice of any physician or dentist duly licensed by an appropriate regulatory agency, or the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of such physician, dentist or hospital. The undersigned shall be liable and agree(s) topay all costs and expenses incurred in connection with such medical, dental and/or hospital services rendered to my child pursuant to this authorization. Should it be necessary for my child to be transported home or to medical facilities due to medical reasons or otherwise, the undersigned shall assume all transportation costs.This Medical Release Form will be used only as necessary in the circumstances. Every reasonable effort will be made to first notify a care giver listed below prior to the use of this Medical Release Form.
Name

Caregiver's First NameLast Name
Relationship to the child:
Signature

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Date

MonthDayYear
Emergency Phone Number

Area CodePhone Number
Name

Caregiver's First NameLast Name
Relationship to the child:
Signature

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Date

MonthDayYear
Emergency Phone Number

Area CodePhone Number
LIMITED ENROLLMENT AGREEMENT FOR CAREGIVERS:

I understand that the number of childrenmatched and admitted is limited by the number of counselors/mentors available, and that age and geography are also limiting factors. As part of the matching process, I give permission for Camp/Mentoring staff to share my child’s Application information (including social worker contact information) with Camp Counselor/MentoringClub leaders in order to better match my child to a qualified mentor.
Should be Empty:

Child's Information

Siblings of Child Applying to RFK Camp/Mentoring

Parent/Guardian Information

Authorized to Pick Child Up at Valley View Baptist at the end of RFK Mentoring each month or the end of camp week.

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 or mentoring time.

Medical History + Prescription Medication Information

Prescription & Over-the-Counter Medications

Medical Release

LIMITED ENROLLMENT AGREEMENT FOR CAREGIVERS: