PERMISSION TO ADMINISTER OVER THE COUNTER DRUGS
We are so glad you have decided to have your child apply for Royal Family KIDS’ Camp this year! A few more steps and you're done.
Child’s First & Last Name ______________________________________
QUESTIONS
For questions on the application, medical cards, required paperwork, space availability, child qualifications for RFKC, if child is moving to a new home, or authorized adult has changed:
Contact: Child Placement Coordinator Jill Kamm:
email jill.kammO@gmail.com, or call; 262-498-1013
I hereby give the Royal Family KIDS Camp Official Medical Staff permission to administer the following products according to manufacturer’s instructions, or as otherwise specified. I trust the RFKC Official Medical Staff to use his or her best judgment as situations arise, and if in doubt, he or she can call for verification.
Please check yes or no for the medications listed below. This form must be completely filled out by the primary caregiver who signs below or camper may not attend camp.
Yes No Specify if desired:
❑ ❑ Sunblock
❑ ❑ Insect repellant
❑ ❑ Lip balm
❑ ❑ Rash ointment
❑ ❑ Tylenol
❑ ❑ Antiseptic ointment
❑ ❑ Band-aids
❑ ❑ Anti-itch cream
❑ ❑ Hydrogen peroxide
❑ ❑ Cough syrup
❑ ❑ Cough drops
❑ ❑ Decongestant
❑ ❑ Antihistamine
❑ ❑ Ipecac syrup
❑ ❑ Other
❑ ❑ Other
❑ ❑ Other
Parent/Legal Guardian’s Signature _________________________________
PERSCRIPTION MEDICATIONS FOR CHILD
I understand that it is my responsibility as a caregiver to make sure that all instructions are clear and that the necessary dosage is adequately supplied for the duration of camp ( Monday morning to Friday afternoon). I hereby authorize Royal Family KIDS’ Camp medical staff (nurse, nurse practitioner, physician’s assistant, physician) to administer the medications from Monday June 19, 2023 to Friday June 23, 2023.
Parent/Legal Guardian’s Signature ________________________________
I understand that my son/daughter participates in activities, which include, but are not limited to: climbing wall, Slip-N-Slide, boating, swimming and other activities. Your child may be exposed to psychologically and physically stressful and challenging situations.
You understand that although RFK & LGYC/CC have taken precautions to provide proper organization, supervision, instructions and equipment for each activity, it is impossible for the program to guarantee absolute safety. I understand there are inherent risks involved in these activities that are beyond the control of the LGYC/CC and RFK staff. Further I waive any claim that may arise against LGYC/CC and RFK or their employees and volunteers as a result of my child's participation.
Participant Name (PLEASE PRINT) _________________________________
Date _________________________________________________________
Parent or Guardian Name (PLEASE PRINT)
______________________________________________________________
Parent/Legal Guardian’s Signature ______________________________
Date _________________________________________________________
MEDICAL RELEASE FORM
This health history is correct so far as I know, and the above named minor has permission to engage in all program activities, except as noted. The undersigned do hereby authorize the directors of 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 physican and surgeon, licensed under the provision of the medicine Practice Act or any dentist 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 participating in any camp program, unless revoked in writing by the undersigned and delivered to the Director of Royal Family KIDS. I give my permission for
(Child’s Name Printed Clearly)
___________________________ to attend Royal Family KIDS Camp in the summer 2023 through Racine Assembly of God.
Parent/Legal Guardian’s Signature ______________________________
Print Guardian Name __________________________________________
Relationship to Child __________________________________________
Date of Signature (Month/Day/Year)____________________________
NO CAMERAS OR MONEY. THESE ITEMS ARE NOT NEEDED AT CAMP.