Camper Application 2026
Please complete this application entirely to have your child considered for camp. If you have questions, please email salemrfk@gmail.com This camp is hosted by Mosaic Church (formerly Family Life) in Salem, OR
Camp Dates: July 13-17, 2026 Mon-Fri Mosaic Church - 1675 Wallace Rd NW, Salem OR
A program of For The Children
Please note: you may save your progress and submit later if needed.
To save your progress, scroll to the bottom and click on the "save progress" button.
Who is filling out this form?
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First and Last Name
What is your relationship to this child?
Birth/Adoptive Parent
Resource/Foster Parent
Case Manager or Staff
Other
Your Phone Number
Please enter a valid phone number.
Child's Information
Child's Name
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First Name
Last Name
Preferred Name (if different)
Gender assigned at birth
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Male
Female
Date of Birth
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-
Month
-
Day
Year
Date Picker Icon
Current Age
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Current Emotional Age (if known)
Child is Living with:
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Foster/Resource Parent
Adoptive Home
Relative
Biological Family
Other
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School
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Grade just completed
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Reading Level/Comfortability
Any developmental delays, learning disabilities, 504/IEP plans at school?
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Child's Shirt Size
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Child Small
Child Medium
Child Large
Child XL
Adult Small
Adult Medium
Adult Large
Adult XL
Child's Pant Size
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PLEASE INDICATE CHILD OR ADULT SIZE
Child's Shoe Size
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PLEASE INDICATE IF CHILD OR ADULT SIZE
Do you know if the child has siblings also attending this camp?
Add Sibling name if YES
If yes, are there any known restrictions in place? Any other helpful info about their relationship?
Adult Information
Name of Primary Caregiver the Child is Living with
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First Name
Last Name
What is your relationship to this child?
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Adoptive Parent
Resource/Foster Parent (non-relative)
Resource/Foster Parent (relative)
Birth Parent
Other
Phone Number of Primary Adult
*
Please enter a valid phone number.
Email of Primary Adult
*
example@example.com
Name of Secondary Adult the Child is Living with
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact
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First Name
Last Name
Emergency Contact's Relationship to Child
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Emergency Contact Phone Number
*
Please enter a valid phone number.
Does child have an assigned ODHS Caseworker at a local branch office? If so, which office?
Caseworker's Office
Caseworker Name
First Name
Last Name
Caseworker Phone Number
Please enter a valid phone number.
Caseworker Email
example@example.com
How many times has child moved in foster care (if known)?
Please select and explain any recent family circumstances or situations that makes camp especially important for this child.
Recent crisis involving child
Separated from sibling(s)
Recently came into care
Recently changed placement
Other
Please Explain the Circumstances:
Camper's Emotional/Behavioral History
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Rows
Daily
Weekly
Monthly
Within the last 6 months
Not at all
Physically Aggressive
Bedwetting
Biting
Eating Disorder
Hyperactive
Lying
Night Terrors/ Nightmares
Problems with Sharing
Running Away
Sexually Acting Out
Stealing
Tantrums (yelling, throwing things, etc)
Withdrawn
If you checked DAILY or WEEKLY above, please describe the behaviors and suggestions to help this child while at camp.
Are there any other significant behaviors we should know about this child? The additional details or examples you provide help the RFKC team provide support during camp.
Your forthright information helps camp staff prepare an enjoyable camp environment for your child.
Does this child have any difficulty with transitions?
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Yes
No
If yes, please explain what that behavior looks like (shutting down, yelling, throwing things, hitting, isolating, crying, etc) and what helps them transition.
This info helps us prepare to support this child as best as possible during the week of camp.
Does this child have any emotional/behavioral triggers (noise, touch, bedtime, mealtime, etc)?
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Yes (or sometimes)
No
If yes, please explain to help us identify and offer support for child.
What are good reinforcement tools/rewards you use to promote positive behavior in this child? (for example: stickers, coloring, stuffed animal, music, verbal encouragement, etc) - Please only include what is applicable at camp (no phones, tablets, etc).
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Does child have any specific strengths, interests, preferred activities, or things they enjoy?
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Examples: sports, art, books, games, rock collection, dancing, favorite character, etc.
Does the child have any activities to be restricted or difficulty with certain activities?
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Is there anything else you would like to tell us about this child or ways they can be supported at camp? Or do you have any concerns?
Camper Details
Child's swimming ability is:
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Good
Poor
Unknown
Other
Child's comfort level around animals (farm animals, horses, dogs, etc) is:
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Good
Poor
Unknown
Other
Do you expect the child will change placements before, during, or shortly after the week of camp?
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Yes
No
Do you have any additional comments or info that we should know?
Child's Health History
Indicate all known allergies, illnesses, disabilities, physical limitations, or medical complications.
Food Allergies: Please write all known food allergies (or write "none" or "unknown" accordingly).
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Drug Allergies:
Other Allergies if known: (eg: seasonal hay fever, bees, fragrances, plants etc.)
Illness/Medical Complications:
Please mark only what applies to child if known: approximate date of illness or condition and the severity, any complications, or any residual impairments.
Disabilities/Assistive Devices (glasses/contacts, hearing aids, leg brace, etc):
Does the child have any mental health diagnosis?
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Yes
No
If yes, please explain or describe all mental health diagnoses (examples: ADHD, PTSD, Separation Anxiety, etc)
Immunization History
Please mark if each vaccine is current: (Dates not needed)
DTP Series (Diphtheria, Tetanus, Pertussis) - (4 or 5 doses)
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Yes
No
Unknown
Tdap (Tetanus, Diphtheria, Pertussis) - (1 dose typically at middle school age)
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Yes
No
Unknown
Hepatitis A - (2 doses)
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Yes
No
Unknown
Hepatitis B - (3 doses)
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Yes
No
Unknown
MMR (Mumps, Measles, Rubella) -
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Yes
No
Unknown
Chickenpox (Varicella) - (2 doses completed by age 6)
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Yes
No
Unknown
IPV (Inactivated Polio Vaccine) -
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Yes
No
Unknown
Prescription Medications
** ALL MEDICATIONS SENT TO CAMP MUST BE IN THE ORIGINAL CONTAINER WITH THE PHARMACY LABEL ON IT **
Is the child taking any medications? (this includes inhalers and epi-pens)
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Yes - fill in the following info below
No
Please write all medications this child takes including dosage, times per day, and reason for taking medication(s).
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Does the child have any challenges taking medication?
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Yes
No
If yes, please explain and offer suggestions to help child.
Doctor's Name and Office (if known)
Doctor's Name
Doctor's Office
Doctor's Phone Number (if known)
Please enter a valid phone number.
Child's Health Insurance Carrier (if known)
Please add any other comments relating to Health and Medications.
Select to agree
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I understand that it is my responsibility as a caregiver to make sure all instructions are clear and that the information and dosage(s) is adequately supplied for the duration of camp. I hereby authorize Royal Family KIDS Camp's Nurse to administer the above medication(s) during the week of camp.
Permission to Administer Over-the-Counter Medications
Permission:
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I hereby give the RFKC Nurse permission to administer the following products according to the manufacturer's instructions, or as otherwise specified. I trust the RFKC Nurse to use his/her best judgement as situations arise, and if in doubt, the Nurse can call for verificaiton.
By checking yes, I hereby authorize the camp nurse to administer the following:
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Rows
Yes
No
Tylenol
Ibuprofen
Insect Repellant
Neosporin
Anti-itch Cream
Rash Ointment
Antiseptic Ointment
Burn Gel
Eye Drops
Cough Drops
Cough Syrup
Tums
Decongestant
Antihistamine
Hydrogen Peroxide
Other
If other, please list here.
I agree to the Medical Release Form Terms and Conditions
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This health history is correct to the best of my knowledge, and the above named minor has permission to engage in all the prescribed program activities, except as noted. The undersigned do hereby authorize the directors of Royal Family KIDS Camp - Salem, 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 advisably and to be rendered under the general or special supervision of any physician and surgeon, 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 enroute 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 KIDS Camp as legal guardian/social worker/other. I give my permission for the stated child to attend Royal Family KIDS Camp through Mosaic Church (formerly Family Life).
By typing an electronic signature below, I agree to all terms, conditions, and authorizations in this form. Legal Guardian Name:
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First Name
Last Name
Today's Date
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Month
-
Day
Year
Date Picker Icon
Person(s) authorized to pick up child at the end of camp: (This person will be required to show ID)
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Save Progress
Submit
This Royal Family KIDS Camp is hosted by: Mosaic Church (formerly Family Life) - 1675 Wallace RD NW, Salem Oregon
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