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! Thanks for sticking with us
-----------------> This release form is for :
Child’s First and Last Name ______________________________________
This paperwork must be signed by a legal guardian and mailed back to:
Royal Family Kids
℅ Chris Oertel
1325 Airline Rd.
Racine, WI 53406
For questions on the application, Medical Cards, Required paperwork call Jill Kamm at 262-498-1013 email@example.com
For questions regarding space available, whether or not your child qualifies for RFKC, if child is moving to a new home, or authorized adult has changed Email RFKC, Child Placement Coordinator Jill Kamm at 262-498-1013 firstname.lastname@example.org
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
PERSCRIPTION MEDICATIONS FOR CHILD
I understand that it is my responsibility as a caregiver to make sure that all instruction 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 25th 2018 to June 29, 2018
--------------------------> Parent/Legal Guardian’s
I understand that my son / daughter participation in activities, which include,but not limited to, the
following Climbing Wall, Slip N Slide Boating, Swimming or other Activities, Your child may be exposed to psychologically and physically to stressful and challenging situation. You understand too 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 and appreciate that there are a number of inherent risks involved in these activities that are beyond the control of the LGYC/CC and RFK or their staff. Further I waive any claim that may arise against LGYC/CC and RFK or their employees and volunteers as a result of His / Her’s Participation.
Participant’s Name(PLEASE PRINT) _________________________________ Date___________
Parent or Guardian Name(PLEASE PRINT)
Parent or Guardian 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 prescribed 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 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 involved or participating in any camp program, unless revoked in writing by the undersigned and delivered to the Director of Royal Family KIDS’ as legal guardian/caseworker/other. I give my permission for (child’s first name printed clearly) ___________________________ to attend Royal Family KIDS Camp in the summer 2018 through Racine Assembly of God.
----------------------> Parent/Legal Guardian’s
Print Name ________________________________________________
Relationship to Child ________________________________________
Date of Signature (Month/Day/ Year)____________________________
PLEASE NO CAMERAS OR MONEY. THESE ITEMS ARE NOT NEEDED AT CAMP.