CAMPER Application 2025 Kids' Armor of Hope (July 27-Aug 1)

CAMPER Application 2025 Kids' Armor of Hope (July 27-Aug 1)
Are you a returning Camper:*

YesNo
Camper's Name*

First NameLast Name
Camper's Preferred Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*
Birthday*
Age*
Current Emotional Age*
Schooling*

Street Address

Street Address Line 2

SchoolGrade

Reading Level
The child is living with:*

Foster ParentGroup HomeParentsRelative
Primary Caregiver(s)
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship to the Child*
Social Worker
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Is the camper currently seeking counseling or therapy?*

YesNo
Referred By:*

CPSCASAPRCACOther
If you chose "Other" please list who.
Camper Sizes
T-Shirt Size*

CHILD: SmallADULT: SmallCHILD: MediumADULT: MediumCHILD: LargeADULT:Large
Shoe Size*
Please list youth or adult
Pant/Short Size*
Please list youth or adult
Camper Details
How many times has the camper moved into Foster Placement?*
Please explain any past and current circumstances and instances that can impact their time at camp: *
For example: recent crisis, reason for foster placement, severe economic needs, disorders and/or behaviors stemming from traumatic life changes, etc.

Please check all behaviors*

	Daily	Weekly	Not at all
Aggressiveness
Bedwetting
Biting
Eating Disorders
Hyperactive
Learning & Disabilities
Lying
Night Terrors
Nightmares
Runs Away
Sexual Acting Out
Steals
Tantrums
Withdrawn

Triggers to Note*
If there are none known, please type "none"
Sleeping Habits to Note*
If there are none known, please type "none"
Eating Habits to Note*
If there are none known, please type "none"
This child's swimming ability is:*

GoodPoorDo not know
Learning Disabilities*

YesNo
If you answered "Yes" to the previous question please list:
Health History

Indicate all known allergies, illness, disabilities, physical limitations or medical complications. If there are none known please type "none":
Allergies*
Illness/medical complications*
Disabilities/Limitations*

Indicate date of illness, severity, complications, and any residual impairments to any that are applicable: *

	Date	Severity	Complications	Residual Impairments	Does Not Experience
Leg or Arm Braces
Hearing Aids
Eating Disorder
Respiratory Problems
Heart or Circulation
Pulmonary Edema
Hay Fever
Balance Problems
Insect Bites
Hypoglycemia
Dizzy Spells
Back
Anaphylactic Shock
Diabetes
Drug Allergy
Musculoskeletal Allergies
Foot
Seizure Disorders
Poison Oak/Ivy
Other

Details from any items above:*
Any specific activities to be encouraged?*
Any specific activities to be restricted?*
Immunization History

Please provide copy of shot records if available.
Date of Last Tetanus Shot:*
Prescription Medications

All medication sent to camp must be in original container with the pharmacy label on it.
Doctor Name*
Doctor Phone Number
Please enter a valid phone number.
Is your child taking any medications?*

NoYes, please fill out the following:

Prescriptions

	Name	Dosage	Times	Reason for Medication
Prescription 1
Prescription 2
Prescription 3
Prescription 4

Please add any other comments related to HEALTH and MEDICATIONS here:*
If there are none, please type "none"
Please indicate below the following products you give permission to Kids Armor of Hope and its Registered Nurse to administer upon their best judgment as situations arise, and if in doubt, will call the care giver for verification.

Please type an "X" in the YES or NO box for the medications listed below. This form must be completely filled out by the primary caregiver who signs below, or camper may not attend camp.

	Yes	No	Specify Instructions if any:
Insect repellant
Rash ointment
Tylenol
Antiseptic ointment
Anti-itch cream
Hydrogen peroxide
Cough syrup
Cough drops
Decongestant
Antihistamine
Lipecac syrup

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 KAH and KAH’s nurse to administer the above medication from dates July 27 - August 1, 2025*

I agree to this statementI DO NOT agree with this statement
MEDICAL AND RELEASE FORM
The behavioral and health history provide 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 Kids Camp, Kids’ Armor of Hope, Inc. and Glen Lake Camp or such substitute as they may designate as agent for the undersigned to consent to an X-Ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care for the above minor which is 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.

This authorization will remain effective while the above minor is in route to and from or 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.
Please check each of the following:*

I understand that it is my responsibility as the caregiver to make sure that the information provided is accurate for the safety of my camper.I understand that it is my responsibility as the caregiver that all medication instructions are clear, and the necessary dosage is adequately supplied for the camper’s time at camp.I hereby authorize Kids Armor of Hope, Royal Family Kids Camp and their Registered Nurse to administer provided medications, as well as any over the counter medications my camper is in need of.I also hereby give my consent for the child in my care to attend Royal Family Kids Camp organized by Kids Armor of Hope.I understand that if my child becomes a threat to either themselves or other campers and staff, that they will be asked to leave camp.
Please provide any further information not covered in this application that you think will be beneficial for the Camp Directors while your camper attends camp.
Person 1 Authorized to pick-up child:*

First NameLast Name
Person 2 Authorized to pick-up child:*

First NameLast Name
Person 3 Authorized to pick-up child:*

First NameLast Name
Authorized Signature*

Powered by Jotform SignClear
Name*

First NameLast Name
Relationship to Child*
Date*

MonthDayYear
Date
Should be Empty:

CAMPER Application 2025 Kids' Armor of Hope (July 27-Aug 1)

Primary Caregiver(s)

Emergency Contact

Social Worker

Camper Sizes

Camper Details

Health History

Immunization History

Prescription Medications

MEDICAL AND RELEASE FORM