Child Application 2023

Child Application

Camp Dates: June 19, To June 23, 2023
Name of Person Filling Out This Application*

First NameLast Name
Relationship to Child

CaseworkerFoster PatrentAdoptive ParentBiological ParentRelativeOther
Child's Information
Child's Name*

First NameLast Name
Child's Preferred Name*
Is this child a returning RFK camper?*

Yes, returning RFK camperNo, not a returning RFK CamperDon't know if child has been to RFK camp before
If child is a returning RFK camper and had a DIFFERENT NAME LAST please let us know

First NameLast Name
If yes, what year, city, and state
Gender*

MaleFemale
Birthdate*

MonthDayYear
Age at Time of Camp June 19 2023
This child will be entering this grade in the fall of 2023*
Emotional Age of Child*
Child's T - Shirt Size*
Are you interested in finding out how your child can be a part of the RFK Club and Mentors Program throughout the 2023--2024 school year?
Parent/Guardian Information
This home is best described as......*
If this child was adopted, when did you adopt him or her

MonthDayYear
At the time of camp, how long will this child have been living in current home.*
Approximately when was this child placed in the current home?*

MonthDayYear
Total # foster or residential placements for the child including current home
Number of placements*
Mailing Address (for camp response)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent or Legal Guardian*

First NameLast Name
Relationship to Camper*
Phone Number: Best one to contact you*

Area CodePhone Number
The above phone is?
Parent or Guardian #1 E-mail*
2nd. Parent/Guardin
2nd. Parent or Legal Guardian

First NameLast Name
Relationship to Camper
Parent or Guardian # 2nd Best Phone Number

Area CodePhone Number
The above phone is?

Cell PhoneWork PhoneHome phone (land Line)
Parent or Guardian # 2nd. E-mail
AUTHORIZED to Pick up Child at Racine Assembly of God on

Friday June 24, 2022

A IDENTIFICATION ID IS REQUIRED
1st. Authorized individual

First NameLast Name
1st. Authorized Adult Phone Number

Area CodePhone Number
2nd. Authorized individual

First NameLast Name
2nd. Authorized Adult Phone Number

Area CodePhone Number
Case Worker/Child Placement Agency Information
Child Placement Agency(Current or Past if child has been Adopted)*
Caseworker Name*

First NameLast Name
Caseworker E-mail*
Caseworker Phone Number*

Area CodePhone Number
Background/Behavior Information

Please fill this out to best of your ability. We as RFK staff want to make sure your child has a safe, healthy, fun time at camp. This information is extremely helpful!
Why would this child's attendance at RFKC be important? Why would you like to see him or her attend camp?*
What specific activities should we encourage your child to try while at camp*
This child's swimming ability is ....?

Poor swimmerGood swimmerExcellent swimmerDon't know swimming ability
If child does wet the bed, please explain ( i.e. wears pull-ups, don't drink liquids after certain times, just need to aware, etc.
How often does the child wet the bed at night?*
Does child display aggressive behavior?*
Please explain aggressive behavior. (What may trigger aggressive behavior or to whom child is aggressive)
Does the child deal with any of the following eating disorders or issues around food?*
If this child has and eating disorder - or has other issues around food we should know about - please explain
How would describe this child's hyperactivity?
If these learning difficulties will negatively affect this camper's week at camp -- or if this information would help the Counselor & Staff make camp better for your child - please explain
How would you describe this attention span?*
Please let us know if any of the following learning difficulties exist for this child.
How often does your child lie?*
If this child has a habit of lying, please explain
Please let us know how often your child has night TERRORS.*
Please let us know how to calm your child or prevent night terrors
Please let us know how often your child has nightmares*
Please let us know how to calm your child or prevent nightmares
Please let us know how often does this child runs away from a situation or from home*
If this child does run away, please explain what calms him or her down or what triggers
Please let us know if - or how - this child acts out sexually.*
If child does act out sexually, please explain.
How often does this child steal things?*
If child does steal or take things, please explain
How often does this child have TANTRUMS or ANGER issue.*
If this child has tantrums or anger issues that are beyond normal childhood frustrations, please explain so we know how to redirect or prevent outbursts
How often does this child withdraw?*
If this child is withdrawn (or certain circumstances cause this), please explain
HISTORY/STORY: Please share this child's history or story so we can undrstand how to give him or her an even MORE amazing week at camp!
**Please tell us about this child's history or story. What situations may have been challenging for this child before living in your home? What circumstances is this child dealing with?*
If this child attended Royal Family KIDS" Camp in the past, what did he or she like about it? What positive changes or behaviors did you see upon their return home?
Please let us know strengths and great, positive things about this child. Please write as much as you like*
Please tell us what this child's interests, passions, loves, etc. are so our staff can make camp even more special! (i.e. Loves sports, interested in horses, favorite color is purple... whatever)*
Any additional information you need for our staff or counselors to know while your child is at camp?
MEDICAL HISTORY + PRESCRIPTION MEDICATION INFORMATION.
List all known allergies to food, plants, medications, animals, etc.*
Date of Last Physical*

MonthDayYear
Illnesses and Medical Complications Past or Present ( check all that apply)*
Please explain each medical issue you checked above. (If you did not check anything, please write in " DOES NOT APPLY"*
What specific activities should be discouraged for medical reasons while at camp?*
Please explain why you said NO to the medications you checked above. (If you did not check any, just say DOES NOT APPLY)
Prescription Medications
I understand that it is my responsibility as a caregiver to make sure that all medications are clear and that the necessary dosage is adequately supplied for the duration of camp (Monday June 19, 2023 to Friday 23 2023) I authorize RFKC medical staff to administer the medications*

Yes, I understand that sharing medical info, medications, and dosages are my responsibility
Prescription or over the counter Medication #1*
Prescription Medication #1: Reason for taking, DOSAGE, and time(s) of day to administer*
Prescription or over the counter Medication #2*
Prescription Medication #2: Reason for taking, DOSAGE, and time(s) of day to administer*
Prescription or over the counter Medication #3
Prescription Medication #3: Reason for taking, DOSAGE, and time(s) of day to administer*
Additional Information we need to know about the above prescription drugs, Vitamins, or over the counter medications sent to camp - or additional meds if any.*
Physician, PA, or NP for Child*

First NameLast Name
Phone Number for Physican, PA, or NP for Child*

Area CodePhone Number
IMMUNIZATIONS: Check immunizations that are NOT UP TO DATE to the best of you ability*

DTP SeriesDTP BoosterTetanus BoosterPolio OPV (Sabin)Measles Vaccine (Live)German Measles
If you checked any of the above immunization saying this child has NOT RECEIVED THEM OR IS NOT UP TO DATE please explain....
If possible please upload a recent color photo of this child (within the last six months). upload a JPG. Photo upload no larger than 1 MG (or 1024 KB) in size
Please SUBMIT this form, then go back to the main menu, and select the REQUIRED CHILD PERMISSIONS FORM from the menu, click PRINT and fill out the form and mail to the address specified on the form
Should be Empty:

Child Application

Child's Information

Parent/Guardian Information

Total # foster or residential placements for the child including current home

2nd. Parent/Guardin

Case Worker/Child Placement Agency Information

Background/Behavior Information