Camper Application 2025
June 9-13, 2025
Background Information
All information will be kept strictly confidential.
Name of Child:
*
First Name
Last Name
Preferred Name for Name Tag at Camp:
*
Gender
*
Please Select
Male
Female
Other
If you marked other, please explain:
Child's Birthday
*
-
Month
-
Day
Year
Date
Child's Current Age:
*
Child's Primary Language
*
Please Select
English
Spanish
Other
Camper's T-shirt Size:
*
Please Select
Child S
Child M
Child L
Adult S
Adult M
Adult L
Adult XL
How did you hear about RFKC?
*
Caregiver's Name:
*
First Name
Last Name
Relationship to Child:
*
Caregiver's Primary Language:
*
Please Select
English
Spanish
Other
Caregiver's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Caregiver's Phone Number:
*
-
Area Code
Phone Number
Caregiver's Email Address:
*
example@example.com
Is your child assigned to a social worker?
*
Please Select
Yes
No
Caseworker's Name:
*
First Name
Last Name
Caseworker's Daytime Phone Number:
*
-
Area Code
Phone Number
Caseworker's Cell Phone Number:
*
-
Area Code
Phone Number
Caseworker's Email:
*
DCFS/Foster Care Agency
*
Camper Information
This information will help us best care for your child during camp. Please note that behavior questions are to help us gain a better understanding of your child so we can best serve them at camp. The purpose is not to disqualify their ability to attend camp.
Has the child attended our Royal Family Kids before?
*
Please Select
Yes
No
If they have attended another Royal Family Kids Camp before, please tell us which one:
Names, if any, of other siblings applying to this Royal Family Kids Camp:
*
What are the two most important things we should know about this child?
*
Explain any unusual family circumstances that make camp especially important for this child. (for example: recent crisis, being moved in foster placement, economic hardship, severe neglect, etc.)
*
Has your child moved homes while in foster care?
*
Yes
No
If so, how many times has your child been moved?
What method(s) of connecting, correcting and empowering works well with this child?
*
Please complete the following:
*
Often
Sometimes
Not At All
Agressiveness
Bedwetting
Biting
Eating Disorder
Hyperactive
Learning Disabilites
Lying
Nightmares
Night Terrors
Runs Away
Sexual Acting Out
Stealing
Tantrums
Withdrawn
Please elaborate on any of these selections above:
Please explain how the behaviors mentioned above present themselves at school:
*
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Permission to Administer Over-the-Counter Medications
I hereby give the Royal Family Kids' Camp Registered Nurse permission to administer the following products according to manufacturer's instructions, or as otherwise specified. I trust the RFKC Registered Nurse to use his/her best judgment as situations arise and, if in doubt, can call for verification. Please select Yes or No for each over-the-counter Medication listed below.
*
Yes
NO
Sun block
Insect repellent
Band-aids
Antiseptic ointment
Antiseptic wash
Anti-itch cream
Cough syrup
Decongestant
Antihistamine
Upset stomach medication
Acetaminophen (Tylenol)
Ibuprofen (Motrin)
Cough Drops
Please sign below as authorization for RFKC's nurse to administer the above indicated over-the-counter medication(s) from 6/9/2025 to 6/13/2025.
Signature
*
Date
*
-
Month
-
Day
Year
Date
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Prescription 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.
If your child is taking medications, please list below. All medications must be in original packaging with pharmacy label on it.
Name of Medication
Purpose
Dosage
When is it taken
1
2
3
4
5
Please sign below as authorization for RFKC's nurse to administer the above indicated prescription medication(s) from 6/9/2025 to 6/13/2025.
Caregiver's Signature
*
Date
*
-
Month
-
Day
Year
Date
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Medical History
Please indicate all known allergies, illnesses and/or physical limitations.
Allergies to any food or medications? If yes please describe the reaction, and if none, type "none".
*
Does your child have seasonal allergies?
*
Please Select
Yes
No
Breathing problems (If none, type "none"):
*
Any illnesses and/or hospitalization for medical or psychiatric reasons? If yes please explain, and if none, type "none".
*
Does this child use assistive devices such as a hearing aid, leg/arm brace, etc.? If so please explain, and if none, type "none".
*
Doctor's Name:
*
First Name
Last Name
Doctor's Phone Number:
*
-
Area Code
Phone Number
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To be Signed at Registration at Nurses' Station on June 9th
I have updated and reviewed the medications with the RFKC Registered Nurse at Registration and am giving consent for them to be administered as stated above.
Caregiver's Signature
Printed Name
Date
-
Month
-
Day
Year
Date
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Emergency Information
This information will be used only if there is an emergency.
Emergency Contact Name (primary person to be notified in case of emergency):
*
First Name
Last Name
Emergency Contact Phone Number:
*
-
Area Code
Phone Number
Emergency Contact's Relationship to child:
*
Emergency Contact Name (additional secondary contact not required):
First Name
Last Name
Emergency Contact Phone Number (additional secondary contact not required):
-
Area Code
Phone Number
Emergency Contact's Relationship to child (additional secondary contact not required):
Name of Person Authorized to Pick Up Child:
*
First Name
Last Name
Phone Number of Person Authorized to Pick Up Child:
*
-
Area Code
Phone Number
Name of Person Authorized to Pick Up Child (additional person not required):
First Name
Last Name
Phone Number of Person Authorized to Pick Up Child (additional person not required):
-
Area Code
Phone Number
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Consent to Travel out of State
This information should be shared with the child's caseworker and you should receive approval from the agency.
Child to travel with Royal Family Kids' Camp, leaving from and returning to Mission Church Bloomingdale, IL Traveling by bus with the Barrington Transportation Co. (847-381-1043) to Lake Geneva Youth Camp, W2655 South Street, Lake Geneva, WI 53147 (262-248-5500). The duration of the trip is June 9-13, 2025. As legal guardian per the "Normalcy Parenting and the Reasonable and Prudent Parent Standard" I give my child consent to travel to camp. By signing below, you are also agreeing that you will get the required approval from your child's caseworker for your child to travel out of state for camp.
Caregiver's Signature
*
Date
*
-
Month
-
Day
Year
Date
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Lake Geneva Youth Camp and Conference Center
W2655 South Street, Lake Geneva, WI 53147, (262) 248-5500
Acknowledgement of Risk and Assumption of Responsibility / Liability Waiver / Hold Harmless
I understand that I may participate in activities in LGYC/CC programs, which include: Archery, Boating, Swimming or other Activities. As a participant engaged in such activities always by my own choice, I assume the risk of injury. I understand the program has taken precautions to provide proper organization, supervision, instruction, and equipment for each activity, however, it is impossible for the program to guarantee absolute safety. Also, I understand that I share responsibility for safety. Further, I waive any claim that may arise against LGYC/CC or its employees as a result of my participation in these activities outside of negligence. I agree to comply with all instructions and directions of Lake Geneva Youth Camp & Conference Center staff during my participation. I acknowledge the risk and assumption of responsibility.
Child's Name
*
Caregiver's Signature
*
Date
*
-
Month
-
Day
Year
Date
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Verfication
By submitting this document and signing below, I certify that the above information is true and correct to the best of my knowledge.
Caregiver's Name
*
Caregiver's Signature
*
Date
*
-
Month
-
Day
Year
Date
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