Camper Registration: Royal Family KIDS Camp August 11 - 15, 2025
This application enables you to register your child for the 2025 Royal Family KIDS Camp - Bronx Chapter, Monday, August 11 through Friday, August 15, 2025. The form requests detailed information about your child's medical information, emotional/behavioral disorders, family history, questions for the safety and security of your child, and specific child characteristics, such as favorite color or likes/dislikes, all so that we can better help your child have a fun-filled week. All information is confidential. This information also helps us place your child with the most appropriate counselor for the week. A small head photo of your child (.jpg or similar) is required to be uploaded on the application. Please fill out ONE APPLICATION FOR EACH CHILD. Foster children ages, 6 - 12, are eligible to attend Camp. Children who have been adopted are allowed to attend camp, however children who have not been adopted and/or are returning campers are the first priority for acceptance to camp. Children in any New York kinship placement programs are also eligible to attend Camp. This application does not guarantee your child a spot at camp. You will be notified if your child has been accepted to Camp no later than July 25. If you have any questions please email info@forthechildrenbronx.org or call our Child Placement Coordinator, Tasha Hickson, at (718) 924-3114 or Pauline Domenech, Director, at (347) 204-0215.
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Child's Name
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First Name
Last Name
Child's Preferred Name, if different from legal name:
Preferred First Name
Date of Birth:
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Month
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Day
Year
Date
Camp Date (Date Picker)
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Month
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Day
Year
Date
Child's Gender:
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Male
Female
Age at time of camp:
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Child's emotional age
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Child's school grade level
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Child's reading level
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Child's T-shirt size
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Please Select
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Child's shoe size (please specify if kids or adults size)
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Child's pant size
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Child's dress size
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Is the child a returning RFK camper?
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Yes
No
If yes, please tell us what year(s)
How did you hear about Royal Family KIDS Camp?
Please upload a recent head shot color photo of this child (within the last six months). Upload a .JPG, or .PNG ONLY. You will not be able to upload a photo larger than 1 MB (or 1024 KB) in size.
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of
Child's home environment
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Foster Home
Adoptive Parents
Group Home
Residential Treatment
Relative
Biological Parent(s)
Other
Siblings of Child Applying to RFKC This Summer
If sibling(s) of this child will also be applying to this camp, please provide their info so we can try and get all siblings to camp this summer. PLEASE MAKE SURE AN INDIVIDUAL APPLICATION IS SUBMITTED FOR THE OTHER SIBLING(S)
Does the child have a sibling/relative who would like to attend this camp
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Yes
No
If the child has siblings/relatives wanting to attend this camp, please tell us who they are.
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Name of person filling out application:
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First Name
Last Name
Relationship of person completing the application for the child:
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Phone Number of person completing the application
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Email of person completing the application
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example@example.com
Parent/Guardian Information
Parent/Legal Guardian, same as person doing app
Parent/Legal Guardian Name:
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First Name
Last Name
Relationship of Parent/Legal Guardian to child:
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Phone Number of Parent/Legal Guardian
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Email of Parent/Legal Guardian
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example@example.com
Address of Legal Guardian:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What date was the child placed in home:
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How many foster or residential placements has the child had, including current home:
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Emergency Contact, same as person doing app
Emergency Contact
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First Name
Last Name
Emergency Contact Phone #
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Emergency Contact email
*
example@example.com
Authorized adult to pick child up at Harvest Fields Community Church
Pick up time is 5:00pm Friday, August 15, 2025
Authorized adults that will be picking the child up will need to show photo Government ID*
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Caseworker/Child Placement Agency Information
Is your child assigned to a social worker?
Please Select
Yes
No
Child's placement/caseworker agency name:
Child's placement/caseworker name:
First Name
Last Name
Child's placement/caseworker phone #
Child placement/caseworker email
example@example.com
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Background/Behavior Information
Please provide this information to the best of your ability. We, as RFKC staff, want to make sure your child has a safe, healthy, fun time at camp. This information is extremely helpful!
Please tell us about this child's history or story. What situations may have been challenging for this child before living in your home? How long and why was this child placed in foster care? What circumstances is this child currently dealing with?
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We expect and look for great things in each and every child. We also know that many of these children have had difficulties in their past which have shaped their present reality. Please give some information about his or her past so we can better understand this child.
Why would this child's attendance at RFKC be important? Why would you like to see him or her attend camp?
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How often does the child have nightmares?
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No nightmares
Rarely has nightmares
Frequently has nightmares
Always has nightmares
Any sleeping concerns? Does the child have difficulty falling asleep? Has the child slept away from home before? Please explain what may trigger the nightmares and what helps the child fall asleep.
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How often does the child wet the bed?
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Never wets the bed
Rarely wets the bed
Frequently wets the bed
Wets the bed every night
Wears a pull-up at night time
How good of a swimmer is the child (check all that apply)?
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Not a good swimmer at all
Needs assistance of a floating device
Somewhat of a good swimmer
Is a great swimmer
Has to stay in shallow waters
Other
Does the child display aggressive behavior?
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Never aggressive
Rarely aggressive
Frequently aggressive
Always aggressive
If needed, please explain more about the aggressive behavior? Please explain what may trigger the behavior or to whom the child is aggressive to and what helps calm the situation when this behavior is displayed.
Does the child bite other children or adults?
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Never bites others
Rarely bites others
Frequently bites others
Always bites others
In needed, please explain what triggers the child to bite?
Does the child have any eating disorders or issues around food (check all that apply)
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Anorexia
Bulimia
Overeating/Gorging
Hording or Stealing food
No eating disorders
Other
If so, please tell us what triggers the eating disorder?
Please explain what may trigger the eating disorder and what may help it.
Does the child have any stool issues or conditions? If so, please explain.
How would you describe the child's hyperactivity(check all that apply)?
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Very calm
Somewhat hyperactive
Always hyperactive
Trouble paying attention
Overly active
Excessively fidgety
Moves about constantly
Takes meds to calm him/her
Other
If needed, please tell us more about the child's hyperactivity. What makes the child hyper or fidgety, and what helps this behavior?
How would you describe the child's attention span?
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Terrific attention span
Sometimes needs redirecting
Attention constantly needs redirecting
Very short attention span
Please let us know if there are any learning difficulties and provide details regarding this specific difficulty.
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Learning difficulties could include: Hearing impairment, Vision impairment, Dyslexia or reading difficulties. If there are any learning difficulties that may affect this camper's week, or if there is information that would help us make camp better for your child, please explain.
How often does the child lie?
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Never lies
Rarely lies
Frequently lies
Always lies
Can't tell lies from the truth
If needed, please explain what may cause the child to lie and what recommendations would you use when this happens?
Please let us know how often this child runs away from a situation or from home?
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Never runs away
Rarely runs away
Frequently runs away
Always runs away
If needed, please let us know what situations may cause this child to run away?
Please let us know if -or how- this child may act out sexually?
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Does not act out sexually
Touches self
Touches other children
Makes inappropriate sexual comments
Flirts or pays inappropriate attention to others
Has sexual history
Other
If needed, please explain any sexual history and what may trigger the acting out.
Please explain what may trigger this behavior and what helps in managing it.
How often does this child steal things?
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ie: Never steals, Rarely steals, Frequently steals, Always steals, Know of stealing in the past, but not recently
How often does the child have tantrums or anger issues?
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Does not have tantrums or anger issues
Rarely has tantrums or anger issues
Frequently has tantrums or anger issues
Always has tantrums or anger issues
Other
What are potential "triggers" for the tantrums or anger? Please describe what an overwhelming anger issue might look like for this child. Please describe possible alternatives to help calm this child.
How often does this child withdraw? What may trigger this behavior? What helps the child to not withdraw or to rejoin the activity?
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How does this child rate on the Autistic scale:
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Mild
Moderate
Extreme
Does not have signs of autisim
Please explain your child's communication skills.
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ie: Great listener, very expressive, likes to talk a lot, very quiet, communication difficulties, lack of interest in other people, lack of eye contact, difficulty in understanding other people's feelings and expressing their own, limited response to social interaction, etc...
Is there any additional behavior information you feel our staff or counselors need to know while your child is at camp? Please share anything that might be helpful!
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Check all the boxes that are true about the child.
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Does the child create a lot of noise?
Does the child crave bright lights, colors or busy pictures?
Does the child like to crash and bump into people, walls, etc.?
Does the child use a lot of force when touching, hugging, or with high fives?
Does the child stomp feet when walking or kick feet when sitting?
Does the child like to be under heavy blankets to sleep?
Does the child love to spin or swing?
Does the child like to hang upside down?
Is the child unaware of messiness on hands or face?
Does the child like to get dirty?
Does the child like bare feet?
Does the child dislike heavy backpacks or heavy blankets?
Does the child become very upset when bumped or pushed, even by accident?
Does the child dislike spinning or doing sumersaults?
Does the child get dizzy easily?
Does the child dislike being upside down?
Does the child dislike being picked up or moved?
Does the child dislike when his/her feet leave the ground?
Does the child dislike tags in clothing, seams in socks, etc.?
Is the child sensitive to certain types of fabrics in clothing and/or sheets?
None of these apply
Is the child sensitive to loud noises?
Camper's Interest
Comments
Child's Favorite Snack
Child's Favorite Color
Child's Favorite Activity/Hobby
Birthday Gift Ideas
Favorite animal
Please tell us what this child's interests, passions, and loves are so our Staff can make camp even more special. What are their strengths, positive traits, and characteristics (i.e. loves sports, crafts, favorite food, favorite color, favorite animals...whatever!)
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Medical History + Medication Information
Physicians Name
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First Name
Last Name
Physicians Phone #
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Is this child current on vaccinations?
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Yes
No
Please explain if this child is not current on vaccinations.
Illnesses and Medical Complications for this child. Please include past or present conditions (check all that apply)
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Respiratory Problems
Muscuoskeletal Allergies
Food Allergies
Medicine Allergies
Topical Allergies (lotion, sunscreen, etc.)
Dizzy Spells and/or Fainting
Foot Problems
Back Problems
Seizure Disorders
Anaphylactic Shock
Balance Problems
Asthma
ADD or ADHD
Hypoglycemia
Heart or Circulation Problems
Pulmonary Edema
Hay Fever
Poison Oak/Poison Ivy Allergies
Type 1 Diabetes (previously insulin-dependent)
Type 2 Diabetes (previously non-insulin dependent)
Insect Bite Allergies (i.e. mosquitoes, bees, wasps, etc.)
Recent Surgery
Recent Broken Bones
None
Other
For this child, please list all known allergies to food, plants, medications, animals, etc.
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Please explain and include any and all additional medical issues we should be aware of that may affect this child while they are at Camp.
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Please check YES or NO giving us approval to administer the medications listed below. This form must be completely filled out by the primary caregiver who signs below, or camper may not attend camp.
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Yes
No
Acetaminophen (Tylenol) 325mg tabs
Acetaminophen Liquid (Tylenol) 160mg/5ml
Ibuprofen (Advil) 200mg tabs
Ibuprofen Liquid (Advil) 100mg/5ml
Diphenhydramine (Benadryl) 25mg tabs
Diphenhydramine Liquid (Benadryl) 12.5mg/5ml
Dextromethorphan (Delsym) 15mg/5ml
Calcium carbonate chewable (TUMS)
Cough Drops (generic)
Phenol spray (Chloraseptic spray)]
Triple antibiotic ointment (neosporin)
Hydrocortisone cream 1%
Hydrogen Peroxide OTC
Solarcaine topical
Immodium (anti diarrhea)
Pepto Bismal liquid and chewables (anti nausea)
Calamine or Caladryl Lotion
Lice treatment/shampoo
Bactine (first aid/antiseptic/pain reliever)
Sunblock/Sunscreen
Lip Balm
Melatonin
Will your child be bringing Prescription and/or Over-the-Counter Medications?
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Yes
No
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. I authorize RFKC medical staff to administer the medications. IMPORTANT: All Medications must be in original container with pharmacy or over the counter label on it. DO NOT pack medication in luggage, you will turn it into the nurse at registration.
Yes, I understand it is my responsibility to supply clear instructions and medical dosage needed and agree for RFKC medical staff to adminster the medications.
Please list ALL prescription and/or over-the-counter medications the child will be bringing to camp.
Any additional information we need to know about any prescription drugs, vitamins, supplements or over-the-counter medications sent to camp for this child?
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ie: Epi pen, Melatonin, sunscreen, bug spray, etc.
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What specific activities should we ENCOURAGE your child to do while at camp?
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What specific activities should be DISCOURAGED while at camp?
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At camp, we have a ratio of 2 campers of similar age paired together with 1 counselor/mentor. Will this scenario work well for the child?
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Yes
No
Please explain what additional support your child may need?
Authorized Signature: I have read the above "Permission to travel, waiver and release of liability" in the Terms & Conditions and the Medical Release and by signing below I agree. It is my intention to exempt and relieve Harvest Fields Community Church, For The Children, and Royal Family KIDS Camp - Bronx leadership from any and all liability. Please sign by using your mouse pad or touch screen.
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