Clone of 2024 Camper Application

RFK Bureau County

Sponsoring Church

The People Church
3525 N. Main Street, Princeton, IL 61356

2026 CAMP DATES: July 26th-July 31st

Contact for questions:

Email: info@rfkbureaucounty.org

Phone Number: 815-915-8229

Cassie Rose - Camp Director

Lauren Mehrkens - Child Placement Coordinator
About the Child

This form should be completed by the caseworker/social worker and/or the foster parent(s). Answer all questions to the best of your ability. Any additional information or clarifications can be sent via email.
Full Legal Name of Camper

First NameMiddle NameLast Name
Preferred Name/Nickname of Camper
Gender of Camper

Other
Age of Camper:
Date of Birth:

MonthDayYear
Date
Estimate of Developmental Age of Camper
Choose all that apply:
Child is currently living with:

Other
(Primary) Name of Person Child is Living With:

First NameMiddle NameLast Name
Best phone number to to contact primary caregiver

Area CodePhone Number
(Secondary) Name of Person Child is Living With:

First NameMiddle NameLast Name
Best phone number to to contact secondary caregiver

Area CodePhone Number
Address Where Child is Living:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail of Primary Contact:

Confirmation Email
Social Worker/Case Worker Name:

First NameMiddle NameLast Name
SOCIAL WORKER/CASE WORKER Phone Number:

Area CodePhone Number
SOCIAL WOKER/CASE WORKER EMAIL:

Confirmation Emailexample@example.com
CHILD Emergency Contact

First NameMiddle NameLast Name
Relationship (of Emergency Contact)
Phone Number (of Emergency Contact)

Area CodePhone Number
Child T-Shirt Size
Child's Shoe Size
Does this child need paraben & sulfate free shampoo for naturally curly hair?
Child's pants/bottoms size: examples: Child Medium (7/8) or Men's Waist 30 or Women's size 9/10
Child's top size:
Child's favorite colors
If child likes college or professional team apparel, please list favorite teams here:Is there anything we should not include in the care package? (e.g., "no jeans", "no collar shirts","nothing red", etc.)
Please tell us a bit more about the child's preferences. Check all that apply.

Other
Childs History
Number of known placements for foster child (including current placement)
Does child have current visitations with biological parent(s)
Please mark all that apply to child's current emotional or behavioral concerns: (The camp Child Specialist will reach out prior to camp to discuss items marked to give the camper the best possible experience at camp).
Other concerns that I would like to discuss with the camp Child Specialist/Licensed Counselor prior to camp:
Has the camper been the victim of sexual abuse?
Has the camper been the victim of physical abuse?
How long has the child been in the care of their present placement?
Camper Details
Please tell us a little about your camper. (This helps us encourage enjoyable and confident participation in activities at camp).
What are some interests of the child? (Movies, TV shows, books, games, animals, ect)
Other characteristics unique to this child you'd like us to know:
Health & Medical History
Please mark all that apply:
Are any activities to be restricted?
Does the child have any of the following known allergies?

Other
Please detail above allergies or describe "other":
Does your child need to have close access to an Epi pen?
Does the camper have asthma?
Dietary Restrictions:
Prescription Medications
Does the child take any medications?
Please list all medications, dosage & reason for taking.

Medication NameDosage Diagnosis or Reason for taking
Medication NameDosage Diagnosis or Reason for taking
Medication NameDosage Diagnosis or Reason for taking
Medication NameDosage Diagnosis or Reason for taking
Medication NameDosage Diagnosis or Reason for taking
Prescribing Doctor's Name

First Name Middle Name Last Name
Doctor Phone Number

Area CodePhone Number
Has the child had any serious illness, injuries, or medical operations in the last three years?
Please list illness or operations:
Are all immunizations current for the camper?
Other medical conditions we need to know about the camper:
Authorized Person(s) to Pick Up Child:

Authorized person(s) will need to show identification and be cleared with Social Worker/Case Workers to pick up child. Children will NOT be released to unauthorized or previously cleared person(s). PLEASE ARRIVE AT PICK UP LOCATION (The People Church) NO LATER THAN 2:30pm on August 2nd
Person Authorized to Pick Up Child:

First Name Middle Name Last Name
Phone Number

Area CodePhone Number
Person Authorized to Pick Up Child:

First Name Middle Name Last Name
Phone Number

Area CodePhone Number
Person Authorized to Pick Up Child:

First Name Middle Name Last Name
Phone Number

Area CodePhone Number
Medical Authorization and Release:

Must be signed by Case Worker/Social Worker or Legal Guardian
Printed Name of Legal Guardian/ Caseworker or Social Worker

First NameLast Name
Signature of Legal Guardian/ Caseworker or Social Worker
We look forward to spending time with your child at CAMP 2026!
If you have questions or need help filling out this form, please reach out to us!

Email: info@rfkbureaucounty.org

Phone Number: 815-915-8229
Should be Empty:

About the Child

Childs History

Camper Details

Health & Medical History

Prescription Medications

Authorized Person(s) to Pick Up Child:

Medical Authorization and Release:

We look forward to spending time with your child at CAMP 2026!