Clone of RFKC NEW RFK Camper Application 2021

Sponsored by Brightmoor Christian Church 40800 W 13 Mile Rd Novi MI 48377

Instructions: This form must be completely filled out without closing the active session/tab. * indicates a required field. If the page will not allow you to submit, then check for a missing entry of a required field. Your application will not be processed until all information has been received.

Please mark your calendar with these important dates:

CAMP is August 10th -14th

If you have any questions throughout this application, please send an email to rfkcampnovi@gmail.com.

Child's Name

First NameLast Name

Child's Preferred Name

DHS Case #

Sex

Birth Date

Date

Age

Cognitive Age

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

School

Grade Entering in Fall 2026

Reading Level

T-Shirt Size

Shoe Size

Has the child attended Royal Family Kids Camp in the past?

Which Royal Family KIDS Camp location?

Date entered into foster care:

Date

Date entered into current placement:

Date

Is the child legally adopted?

How many placements has the child experienced?

Are the birth parents still involved with the child?

Are any siblings currently in foster care?

What are the siblings names and ages?

Are there any other foster children placed in the same home that may attend Royal Family Kids Camp?

What are their names and ages?

Please describe any changes to routine, behaviors, or environment that the child has experienced due to the COVID-19 pandemic:

Please share some background information that would be beneficial to the child's counselor at Camp:

Has your child been in your care for less than 3 months and/or is your child placed in a residential facility?

Camper's Emotional/Behavioral History

Rows	Often	Sometimes	Not at all
Aggressiveness
Bedwetting
Biting
Eating Disorder
Hyperactive
Overwhelmed in Groups
Lying
NIght Terrors
Nighmares
Runs Away
Sexually Acting Out
Steals
Tantrums
Withdrawn

Additional explanations for the above responses

What are some typical warning signs that your child is becoming escalated? (If none type NA)

What are some typical triggers that will escalate your child? (If none type NA)

What are some coping skills or strategies that you or your child have used when he or she is escalated? (If none type NA)

Does your child have any known allergies, illnesses, disabilities, or physical limitations

Indicate any known allergies, illnesses, disabilities, or physical limitations

Is this a sexual abuse case?

Immunization History: Please email a copy immunization record to campers@novirfkids.org or upload below:

Immunization record **This can be emailed at a later date if not currently available:

Browse Files

Is the child taking any prescription medications?

Please fill in the following:

Rows	Name	Dosage	Time
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5

Physician's Name

First NameLast Name

Physician's Phone Number

Area CodePhone Number

Child's insurance provider

Child's insurance number

IMPORTANT NOTE: MEDICATIONS MUST BE IN ORIGINAL PERSCRIPTION BOTTLES FROM PRESCRIBING PHYSICIAN. Campers must be accompanied by proper dosages for the duration of the camp week.

I give the the Royal Family Kids camp nurse permission to administer the following over the counter products according to manufacturer's instructions, or as otherwise specified, if needed. Please check any that you DO NOT wish to be administered. The Royal Family Kids camp registered nurse will use their best judgement as situations arise, and if in doubt, he/she will call for verification.

I hereby authorize Royal Family Kids camp nurse(s) to administer medication from 08-10-2026 to 08-14-2026

Print your name

First NameLast Name

Signature

Medical Release: 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 Novi Royal Family Kids 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 or surgeon, liscensed under the provision of the Medicine Practice Act or any dentist liscensed 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 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 directors of Novi Royal Family Kids camp as legal guardian/foster care case manger/other.

I give my permission for the following child to attend Royal Family Kids camp and be treated medically if needed

First NameLast Name

Print your name

First NameLast Name

Signature

My relationship to the child is:

Print your name

First NameLast Name

Signature

My relationship to the child is:

Name of foster parent/legal guardian child is living with

First NameLast Name

Foster parent/legal guardian phone number

Area CodePhone Number

Foster parent/legal guardian e-mail

example@example.com

Best way to contact foster parent/legal gaurdian?

Alternate contact person

First NameLast Name

Relation of alternate contact to child

Email of alternate contact to child

example@example.com

Alternate contact phone number

Area CodePhone Number

Is there a Foster Case Specialist working with the camper?

Foster Case Specialist

First NameLast Name

Foster Care Specialist Day Phone

Area CodePhone Number

Foster Care Specialist Emergency Phone

Area CodePhone Number

Foster Care Specialist E-mail

example@example.com

Do you require permission from multiple guardians?

How many additional signatures are needed?

Name of alternate guardian #1

First NameLast Name

Relation of alternate contact #1 to child

Does guardian #1 have access to email?

Alternate guardian #1 e-mail

example@example.com

Name of alternate guardian #2

First NameLast Name

Relation of alternate contact #2 to child

Does guardian #2 have access to email?

Alternate guardian #2 e-mail

example@example.com

Name of alternate guardian #3

First NameLast Name

Relation of alternate contact #3 to child

Does guardian #3 have access to email?

Alternate guardian #3 e-mail

example@example.com

Name of alternate guardian #4

First NameLast Name

Relation of alternate contact #4 to child

Does guardian #4 have access to email?

Alternate guardian #4 e-mail

example@example.com

Kids who have attended Royal Family KIDS Camp can apply for Royal Family KIDS Club. RFK Club will provide fun times with their own matched adult mentor (trained and cleared) for 4 hours a month plus once-a-month Club time events during the school year. Approved Mentors can help with transportation and there is no fee for participation. Club participation includes a backpack, club shirt and other Club materials.

Are you interested in your child attending Royal Family KIDS Club next school year?

LIMITED ENROLLMENT AGREEMENT FOR CAREGIVERS: By selecting yes in the question above I understand that the number of children matched and admitted is limited by the number of mentors available, and that age and geography are also limiting factors. As part of the matching process, and I give permission for Camp staff to share my child’s Camper Application information (including social worker contact information) with Club leaders in order to better match my child to a qualified mentor.

If a mentor is available, you will be contacted by the Club Mentoring Director later in the summer to discuss the match with a qualified mentor for your child during the next school year.

By signing below, I certify all information in this application is true and correct to the best of my knowledge:

Print your name

First NameLast Name

Signature

Comments or Questions

2026 Royal Family Kids Camp Camper Registration Form

Camper Information

Camper History

Camper Medical Information

Foster Parent/Legal Guardian Information

Royal Family KIDS Mentoring Club Program

THANK YOU!