Gardendale Royal Family Kids' Camp - Camper Application 2018

Gardendale, AL Royal Family KIDS Camp - Camper Application 2018

July 9th to 13th, 2018
Thank you for applying for your child to attend our summer camp, sponsored by Gardendale-Mt. Vernon UMC in Gardendale, Alabama. This camp is open to children with current or past history of neglect and abuse leading to foster care placement. We are very blessed to be able to serve these children each summer! The camp is a sleepover camp, and there is no charge. Please complete this application form thoroughly, as we do not have unlimited slots for campers. Also, please note that there are two application pages and a horse program participation form that must be printed and signed. Completing this online form does not complete the entire application.
CAMPER'S GENERAL INFORMATION
Camper's Last Name:*
Camper's First Name:*
Camper's Preferred Name:
Camper's Gender:*
Please submit a photo of the camper. If you have an image you can upload from your computer, please select "Choose File."

Upload a File

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Camper's Date of Birth:*

MonthDayYear
Note: Campers must be age 6-11 at camp time, July 9th to 13th, 2018.
Camper's Age During Camp Week (July 9th to 13th, 2018):*
Camper's Current Emotional Age (please make your best estimate):
Camper's Street Address:*
Camper's City:*
Camper's State:*
Camper's Zip Code:*
Camper's School:
Camper's Grade Level:*
Camper's Reading Level:
Does the camper have any learning disabilities?*
Please explain.
Camper's Swimming Ability:*
Would the camper enjoy horseback riding?*
Please Note: Trained professionals assist the children with horseback riding at camp. The Horse Program Participation Form included with the printable packet must be signed and returned in order for the camper to ride. Horseback riding is not required if a child prefers not to participate.
Camper's T-shirt Size:*
Camper's Favorite Color:*
How many times has the camper been moved in foster care?
Please explain any unusual circumstances that make camp especially important for the child. Examples: recent crisis, being moved in foster placement, severe economic needs, etc.
Has the child ever attended another Royal Family KIDS Camp besides this one?
Which Royal Family KIDS Camp did the child attend? If you know the sponsor church or location, please provide that information.
Is the child registered for another Royal Family KIDS Camp this summer?
Which Royal Family KIDS Camp will the child be attending besides this one? Please provide the sponsor church or location.
CAREGIVER INFORMATION
Name of the person completing this form:

First NameLast Name
The camper is currently living with:*
If you selected "other" in the previous question, please specify here:
Name of the person the camper is living with (caregiver):*
Caregiver's Primary Phone Number:*
Caregiver's Work or Secondary Phone Number:*
Caregiver's E-mail Address:
Emergency Contact Person Other Than the Caregiver Listed:*
Emergency Contact Person's Phone Number:*
Emergency Contact Person's Relationship to the Child:*
SOCIAL WORKER INFORMATION
Does the camper have a social worker?
Social Worker's Name:*
Social Worker's Agency or Employer:*
Social Worker's Primary Phone Number:*
Social Worker's Secondary Phone Number (After Hours):
Social Worker's E-mail Address:*
Please click "Next" to go to the next part of the application.

	Issue for Child?
Respiratory Problems
Heart or Circulation Problems
Pulmonary Edema
Hay Fever
Balance Problems
Reaction to Insect Bites
Hypoglycemia
Dizzy Spells
Back Problems
Anaphylactic Shock
Diabetes
Drug Allergies
Musculoskeletal Problems
Foot Problems
Seizure Disorders
Poison Ivy/Oak
Fainting
Other

INSTRUCTIONS FOR APPLICATION COMPLETION

Please read the following instructions carefully, as additional printed documents must be submitted to complete the application and ensure a placement in camp or on a waiting list. Please remember to hit the submit button to complete the online portion of the application after you have downloaded the additional documents.

Submitting an application does not guarantee a camp position for your child. Our slots are limited by the number of volunteers who serve so that we can provide the safest environment for your child. Please note that camp positions will be prioritized as follows:

Returning campers have first priority, as long as their COMPLETE applications are returned by May 1st, 2018.

New campers who are still in the foster care system have second priority, as long as their COMPLETE applications are returned by June 1st, 2018. We always have positions for new campers still in foster care.

New campers who have a prior history of being in the foster care system, but who have returned to their biological families or have been legally adopted have third priority.

We will notify you of your child's acceptance into camp as soon as we can do so. Please note that placements may not be made until sometime in June if your camper is a new applicant.
Medical Information and Permission Forms Requiring Signatures on Paper

There are three pages that must be printed, signed, and returned to complete the application. One requires a physician's signature. There is also a permission form for our horse program. Please download these items here, print, and complete them as soon as possible.

Note: if you are a social worker or foster parent and your DHR office will not allow you to sign the horse program permission form as written, please contact David Ansardi at dansardi@gmail.com or 205-913-2594 for more information.

These signed, completed pages and an updated immunization record must be submitted to complete your camper's application.

Return these items to:

David C. Ansardi

Child Placement Coordinator

Gardendale – Mt. Vernon United Methodist Church

805 Crest Drive Gardendale, AL 35071

FAX: 1-888-243-5479

dansardi@gmail.com (scan and send as an attachment)

Phone: 205-913-2594

A COPY OF THE CHILD'S IMMUNIZATION RECORDS (BLUE FORM) MUST BE SUBMITTED IN ADVANCE OF CAMP.

PLEASE DON'T FORGET TO HIT THE SUBMIT BUTTON BELOW!
Should be Empty:

	Often	Sometimes	Not At All
Aggressiveness
Bedwetting
Biting
Overeating
Undereating/Anorexia
Hyperactivity
Lying
Night Terrors/Nightmares
Running Away
Sexually Acting Out
Stealing
Tantrums
Withdrawn Behavior

Gardendale, AL Royal Family KIDS Camp - Camper Application 2018

CAMPER'S GENERAL INFORMATION

CAREGIVER INFORMATION

SOCIAL WORKER INFORMATION

CAMPER'S EMOTIONAL AND BEHAVIORAL HISTORY

CAMPER'S HEALTH HISTORY

PRESCRIPTION MEDICATIONS

INSTRUCTIONS FOR APPLICATION COMPLETION

Medical Information and Permission Forms Requiring Signatures on Paper