2026 RFK CITRUS COUNTY Camper Application

2026 RFK CAMPER APPLICATION

Sponsored by Calvary Church 2728 E Harley St. Inverness, Fl 352-637-5100 Camper applicant must be between the ages of 7-11 on June 1, 2026.
QUESTIONS?

If you have questions or concerns about RFKC Inverness please contact our volunteer Child Placement Coordinator Nicole Howard at RFKC.citrus@gmail.com

You will be contacted by our Child Placement Coordinator who will talk to you further about this application once submitted.
CAMP WEEK: JUNE 1-JUNE 5, 2026
Child's Name

First NameLast Name
Preferred Name for Name Tag
Please upload a picture of the child.

Cancelof
Home Mailing Address (for camp correspondence)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate

MonthDayYear
Biological Sex

MaleFemale
Age of Child on June 1, 2025

6789101112
Current Emotional Age (if different than actual age)
Child's School
Child's Current Grade
Child's Reading Level
Child's T-Shirt Size
Pant Size
Shirt Size
Shoe Size
PARENT/GUARDIAN INFORMATION
This child lives with...
How long has this child lived in the current home?
# of foster/residential placements for child since removal
Parent/Guardian's Name

First NameLast Name
Parent/Guardian's Relationship to Child
Parent/Guardian's Phone #
Please enter a valid phone number.
Parent/Guardian's Email Address
example@example.com
2nd Authorized Adult (in case we can't reach you we need another adult we can contact)

First NameLast Name
2nd Authorized Adult's phone #
Please enter a valid phone number.
AUTHORIZED TO PICK CHILD UP FROM CAMP

Pick up on Friday, June 5, 2026
Name of authorized adult that can pick up child on June 5th from camp *Photo ID required for pick up.

First NameLast Name
1st Authorized Adult phone # (for camp pick up)
Please enter a valid phone number.
Name of authorized adult that can pick up child on June 6th from camp *Photo ID required for pick up.

First NameLast Name
2nd Authorized Adult phone # (for camp pick up)
Please enter a valid phone number.
CASEWORKER/CHILD PLACEMENT AGENCY INFORMATION
Caseworker Name

First NameLast Name
Caseworker Phone #
Please enter a valid phone number.
Caseworker Email Address
example@example.com
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.
Type of abuse child has experienced (check all that apply)?

Physical AbuseNeglectSexual AbuseOther
Please tell us about this child's history or story. What events led to the child receiving involvement from Department of Children and Families (DCF) or removed from their home?
Why do you want this child to attend camp?
Please rate this child’s ability towards aggression or trouble controlling anger.

1

2

3

4

5

1 is Difficult, 5 is Great
Does the child deal with any of the following eating disorders or issues around food?

Anorexia / BulimiaOvereating / GorgingHoarding or Stealing FoodNo known eating disorders
Please explain more about food issues child may have.
Rate child's activity level

1

2

3

4

5

1 is No Concern, 5 is Hyperactive
How often does your child lie?

1

2

3

4

5

1 is No Concern, 5 is Lies Often
How often does this child run away from a situation or from home?

1

2

3

4

5

1 is Never Runs, 5 is Runs Away Often
Please let us know if this child sexually acts out inappropriately. Choose all behaviors you have seen.

Not a concernTouches selfTouches other childrenInappropriate attention to peers or adultExposes themselves
If this child does act out sexually, please explain.
Child has displayed self harming behavior or suicidal thoughts or actions.

NoYes (explain below)
Please explain
Does the child take things that do not belong to them?

NoYes
How shy do you feel this child is?

1

2

3

4

5

1 is Not a concern, 5 is Very Shy
CAMPER PERSONALITY: Share some strengths about this child (ie kind, optimistic, determined, athletic, friendly)
Please tell us what are this child's interests, passions and loves. (i.e. Loves sports, interested in horses, favorite color)
BIRTHDAY PARTY: We have a Birthday Party for the campers every year. Please list 3 gifts ideas in the $20 price range. No gift cards, electronics, games, clothing please. Be Specific (ie RC Cars, Nerf, Barbies, Legos, Baby Dolls, Art Kits, Nail Kits)

Remote Control CarNerf GunBarbiesLegosBaby DollsNail KitsArt/Craft KitsJewelry Making SuppliesTECH Decks (tiny skate boards)Pokemon Sets18 Inch Dolls
Specific Birthday Gift Ideas
MEDICAL HISTORY + PRESCRIPTION MEDICATION INFORMATION
This child was in enrolled in public or private school this year.

YesNo (please upload immunization records below)
Attach a Copy of Child's Immunization Records (not required if child was enrolled into public or private school for this year)

Cancelof
This child's swimming ability

1

2

3

4

5

1 is Weak, 5 is Strong
Child's Medical History (check all that apply)

Respiratory ProblemsSeasonal AllergiesFood AllergiesMedicine AllergiesTopical Allergies (lotion, sunscreen etc)Dizzy Spells and/or FaintingBack ProblemsSeizure DisordersAnaphylactic ShockBalance ProblemsAsthmaAutism / Autism Spectrum DisorderADD or ADHDHypoglycemiaHeart or Circulation ProblemsPulmonary EdemaType 1 DiabetesType 2 DiabetesInsect Bite Allergies (ie mosquitoes, bees etc)Recent SurgeryRecent Broken BonesHearing ImpairmentVision ImpairmentNone
Please explain any checked medical issue you checked above.
Rate child's difficult with sleeping at night

1

2

3

4

5

1 is No Problem, 5 is Struggles Nightly
If you rated at 4 or 5, please explain more and share what helps:
Does this child wet the bed at night?

NoSometimesYes
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.). This is just so we know how to best care them at camp.
PERMISSION TO ADMINISTER

OVER-THE-COUNTER MEDICATIONS

I give Royal Family Kids Camp Registered Nurse permission to administer the following products according to manufacturer’s instructions, or/as otherwise specified. RFK Registered Nurse has permission to provide any of the following that is/are needed:

Sunblock
Insect Repellent
Lip Balm
Rash Ointment
Tylenol
Antiseptic Ointment
Band-Aids
Anti-Itch Cream
Hydrogen Peroxide
Cough Syrup
Cough Drops
Decongestant
Antihistamine
Ibuprofen

melatonin
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.

Yes, to everything listed above.No (please list specifics below)
Please share list of specific medicines you do not wanted given to this child from the list above.
PRESCRIPTION & OVER-THE-COUNTER MEDICATIONS

If your child is NOT taking any prescription or over-the-counter medications, vitamins, or inhalers to camp, please skip to the PRIMARY DOCTOR field.
#1 Prescription Medication
#1 Prescription Medication: Reason for taking, Dosage, and Time(s) of Day to Administer and the length of time child has been taking this medicine
#2 Prescription Medication
#2 Prescription Medication: Reason for taking, Dosage, and Time(s) of Day to Administer and the length of time child has been taking this medicine
#3 Prescription Medication
#3 Prescription Medication: Reason for taking, Dosage, and Time(s) of Day to Administer and the length of time child has been taking this medicine
#4 Prescription Medication
#4 Prescription Medication: Reason for taking, Dosage, and Time(s) of Day to Administer and the length of time child has been taking this medicine
#5 Prescription Medication
#5 Prescription Medication: Reason for taking, Dosage, and Time(s) of Day to Administer and the length of time child has been taking this medicine
Please continue your child's medication through camp and do not make any medicine changes until after they return from camp

I have read the above and will be mindful of that request
Child's Primary Doctor

First NameLast Name
MEDICAL PERMISSION:

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. 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 2026.
Authorized Adult Signature:

Clear
Authorized Adult

First NameLast Name
PERMISSION TO TRANSPORT:

The above-mentioned organizations, are hereby authorized to transport said minor by bus from the registration location in Inverness, FL to the campground on June 1st , 2026, and transport the minor from the campground to the pick-up location in Inverness, FL on Friday, June 5th, 2026. I understand that if I should, for any reason, desire to retrieve said minor from camp before Friday, June 5th, 2026, I will first be required to make arrangements with the directors and meet at an agreed upon location. By my signature, I release Calvery Church and Royal Family Kids Inc, and any other involved parties from liability in relation to travel to and from camp.
Authorized Adult Signature

Clear
Authorized Adult

First NameLast Name
Today's Date

MonthDayYear
Date
Should be Empty:

2026 RFK CAMPER APPLICATION

CAMP WEEK: JUNE 1-JUNE 5, 2026

PARENT/GUARDIAN INFORMATION

AUTHORIZED TO PICK CHILD UP FROM CAMP

CASEWORKER/CHILD PLACEMENT AGENCY INFORMATION

BACKGROUND/BEHAVIOR INFORMATION

MEDICAL HISTORY + PRESCRIPTION MEDICATION INFORMATION

PRESCRIPTION & OVER-THE-COUNTER MEDICATIONS