Royal Family KIDS Mentoring Club Application 2027

Has your child participated in a Royal Family KIDS Camp Program in the past year?

Child's Name

First NameLast Name

Child's Preferred Name

Child's Gender

Child's Birthday

Date

Child's Age

Has the child had a change in living location since the 2026 camper application was completed?

If yes, please provide the updated address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

The child is currently living with:

Caregiver Name

First NameLast Name

Additional Caregiver Name

First NameLast Name

Email address where you would like to receive Club information:

example@example.com

Caregiver Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Caregiver's referred method of contact:

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact's Relationship to Child

Child's Social Worker (if applicable)

First NameLast Name

Social Worker's Contact Number (if applicable)

Please enter a valid phone number.Format: (000) 000-0000.

Please provide the names of the individuals (outside of the listed caregivers) who are authorized to pick up the child.

I understand that the adult(s) named above must show a current picture I.D. to the Mentor/Club volunteer before the volunteer may release the child to their care. Any changes to this form must be submitted to the Mentoring Director or Child Engagement Coordinator.

Child's Shirt Size

Please provide any information or circumstances that make mentoring club especially important for the child OR provide any changes or things of note since we last saw the child at camp.

Aggressiveness

Biting

Eating Disorder

Hyperactivity

Diagnosed Learning Disability

Lying

Running Away

Sexual Acting Out

Stealing

Throwing Tantrums

Withdrawals

Any additional details from above:

Please provide any information about your child's behavior or needs that would be helpful for our staff to know.

Has any of the child's health history, limitations, or allergies changed since the camper application was submitted for 2026?

If yes, please provide any allergies that the child has as well as any medical complications they have experienced or new disabilities/limitations.

Please list any specific activities that the child should NOT participate in:

Is the child up-to-date on state required vaccinations?

Does the child have the same pediatrician as when the camper application was completed for 2026?

Child's Pediatrician

First NameLast Name

Name of Doctor's Office

Is the child currently taking any medications?

Please provide an updated list of the child's medications including name of medication and dosage and time of day that the medication is administered.

I understand that it is my responsibility as a caregiver to allow or deny care for my child. In the event of an emergency, accident, or injury, I hereby authorize Royal Family KIDS Mentoring Club's nurse to administer the above approved medication and/or treat the child as they deem fit with their medical knowledge. I authorize in the event of an emergency for my child to be treated by healthcare professionals as appropriate during their time at club. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical, dental and/or hospital services rendered to my child pursuant to this authorization. Should it be necessary for my child to be transported home or to medical facilities due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

Caregiver Signature

I hereby give the Royal Family KIDS Mentoring Club nurse permission to administer the following products according to manufacturer's instructions, or as otherwise specified. I trust the Royal Family KIDS Mentoring Club nurse to use their best judgement as situations arise, and if in doubt, they can call the caregiver for verification.

Sunscreen

Insect Repellant

Tylenol

Antiseptic Ointment

Band-Aids

Hydrogen Peroxide

Cough Drops

Antihistamine

Please list ANY medications that should NOT be administered to the child:

As the undersigned legal parent or caregiver, I request that my child, be allowed to participate in the Royal Family KIDS Mentoring program.

This Transportation and Activities Permission and Release Form is effective on the date of my signature below and will remain in full force and effect as long as my child participates with Royal Family KIDS programs in any manner.

I hereby give permission for my child to attend and participate in the activities at club. I specifically authorize Royal Family KIDS Mentoring to provide for, and arrange in my place, necessary medical care, as stated in the Medical Release Form on the reverse hereof.

I hereby also give my permission for my child to ride in any vehicle designated by the adult(s) in whose care my child has been entrusted while participating in the Activities.

In consideration for permitting my child to attend and/or participate in the Activities, I do hereby release, and on behalf of my child release, Royal Family KIDS Mentoring program, the local Club’s mentors, Club leaders, volunteer assistants, the host church, and any designated driver of a van, bus, car, or other vehicle used in connection with any of the Activities (“Released Parties”) from any and all claims for injuries, losses, damages, costs and expenses that I, and/or my child, might have against the Released Parties, arising out of, or in any way relating to, my child and the Activities, and I agree to hold the Released Parties harmless from any loss arising from such claims.

Caregiver Approval

Caregiver Signature

Caregiver Printed Name

First NameLast Name

Today's Date

Date

Mentoring Club Application 2027

Emotional/Behavioral History

Health History

Medical Release Form

Permission to Administer Over-the-Counter Medications

Transportation/Activities Permission and Release Form