Camper Application 2026

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?
First and Last Name
What is your relationship to this child?

Other
Your Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child's Information
Child's Name

First NameLast Name
Preferred Name (if different)
Gender assigned at birth
Date of Birth

MonthDayYear
Current Age
Current Emotional Age (if known)
Child is Living with:

Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School
Grade just completed
Reading Level/Comfortability
Any developmental delays, learning disabilities, 504/IEP plans at school?
Child's Shirt Size
Child's Pant Size
PLEASE INDICATE CHILD OR ADULT SIZE
Child's Shoe Size
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

First NameLast Name
What is your relationship to this child?

Other
Phone Number of Primary Adult
Please enter a valid phone number.Format: (000) 000-0000.
Email of Primary Adult
example@example.com
Name of Secondary Adult the Child is Living with

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact

First NameLast Name
Emergency Contact's Relationship to Child
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Does child have an assigned ODHS Caseworker at a local branch office? If so, which office?
Caseworker's Office
Caseworker Name

First NameLast Name
Caseworker Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.

Other
Please Explain the Circumstances:

Camper's Emotional/Behavioral History

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?
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)?
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).
Does child have any specific strengths, interests, preferred activities, or things they enjoy?
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?
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:

Other
Child's comfort level around animals (farm animals, horses, dogs, etc) is:

Other
Do you expect the child will change placements before, during, or shortly after the week of camp?
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).
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?
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)
Tdap (Tetanus, Diphtheria, Pertussis) - (1 dose typically at middle school age)
Hepatitis A - (2 doses)
Hepatitis B - (3 doses)
MMR (Mumps, Measles, Rubella) -
Chickenpox (Varicella) - (2 doses completed by age 6)
IPV (Inactivated Polio Vaccine) -
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)
Please write all medications this child takes including dosage, times per day, and reason for taking medication(s).
Does the child have any challenges taking medication?
If yes, please explain and offer suggestions to help child.
Doctor's Name and Office (if known)

Doctor's NameDoctor's Office
Doctor's Phone Number (if known)
Please enter a valid phone number.Format: (000) 000-0000.
Child's Health Insurance Carrier (if known)
Please add any other comments relating to Health and Medications.
Select to agree
Permission to Administer Over-the-Counter Medications
Permission:

By checking yes, I hereby authorize the camp nurse to administer the following:

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

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:

First NameLast Name
Today's Date

MonthDayYear
Person(s) authorized to pick up child at the end of camp: (This person will be required to show ID)
This Royal Family KIDS Camp is hosted by: Mosaic Church (formerly Family Life) - 1675 Wallace RD NW, Salem Oregon
Should be Empty:

Camper Application 2026

Camp Dates: July 13-17, 2026 Mon-Fri Mosaic Church - 1675 Wallace Rd NW, Salem OR

Please note: you may save your progress and submit later if needed.

Child's Information

Adult Information

Camper Details

Child's Health History

Immunization History

Please mark if each vaccine is current: (Dates not needed)

Prescription Medications

Permission to Administer Over-the-Counter Medications

This Royal Family KIDS Camp is hosted by: Mosaic Church (formerly Family Life) - 1675 Wallace RD NW, Salem Oregon