RFK 392 Armstrong Camper Application

Dear Foster/Kinship Parents or guardians,

We would like to extend an invitation to your child to attend this year’s Royal Family KIDS Camp. Royal Family KIDS Camp is a one-week long overnight camp for children 7 - 11 years old. Camp days are Monday through Friday.

Your child will leave our parking lot from Living Water Church at 629 Woodward Ave, Kittanning, PA 16201 on Monday morning and return Friday afternoon. Our camp facility is about an hour away.

Swimming, nature walks, Bible stories, music and a variety of non-competitive sports and games will round out a program emphasizing wholesome activities and the building of positive memories. There are more than a dozen Activity Centers to choose from, including arts and crafts, games, and sports. Evening activities will include a talent show, a birthday party, and a whole lot more!

The opportunity to develop good attitudes toward peers and to learn about the outdoors will be present everywhere for them. Special guest speakers and entertainers help to make each year a memorable experience. There is one camp counselor for two children in addition to many support staff, so your child will have individualized attention and be well cared for.

All camp staff are trained, background checked, and interviewed before camp to ensure your child will be kept safe during camp.

Please submit the application as soon as possible. Space is limited to the first 24 applicants. There is no cost to you for your child to attend camp, it is free for campers. Once we receive your application and a Xerox copy of your child’s insurance I.D. card, we will send you a letter confirming your child's place and a list of suggested items to bring to camp.

If you have any questions, please call us at 724-951-2012. We are looking forward to another great week at camp this year!

Sincerely,

Kim & Tyler Luke,

Directors

FTCArmstrong@gmail.com

Www.ftcarmstrong.org

Name of Child:*

First NameLast Name

Preferred Name:*

Sex*

NEW first time RFKC Campers: Please upload/ attach a recent picture of your child. *

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Returning campers do not need to submit a photo

Child's Current Age:*

Child's Birthday*

Date

Child's Emotional Age:*

May be different than child's chronological age

Address*

Street Address

Street Address 2

CityState / Province

Postal / Zip Code

Name of School child attends:

Has the child experienced any of the family or caregiver losses below in the last 12 months?

The child is living with:*

Foster ParentGroup HomeRelativeOther

Name of person child is living with:*

First NameLast Name

Phone number of person child is living with:*

Area CodePhone Number

Email Address of person child is living with:*

Emergency Contact Name:*

First NameLast Name

Emergency Contact Phone Number:*

Area CodePhone Number

Emergency Contact's Relationship to child:*

Is your child assigned to a social worker?*

Social Worker's Name:*

First NameLast Name

Social Worker's Daytime Phone Number:*

Area CodePhone Number

How did you hear about Royal Family Kids?

How many times has your child moved been moved in foster care?*

ex: 5

Please explain any unusual family circumstances that make camp especially important for the child:*

	Often	Sometimes	Not At All
Agressiveness
Bedwetting
Biting
Eating Disorder
Hyperactive
Learning Disabilites
Nightmares
Night Terrors
Runs Away
Sexually Acting Out
Steals
Tantrums
Lying
Withdrawn

Please elaborate on any of these selections above or if there are other circumstances not listed above:

Camper's Sensory Seeking Behaviors*

	Yes	No
Does the child create a lot of noise?
Does the child crave bright lights, colors or busy pictures?
Does the child like to be under heavy blankets to sleep?
Does the child love to spin or swing?
Is the child unaware of messiness or hands or face?
Does the child like to get dirty?

Please elaborate on any of the selections made above:

Camper's Sensory Avoiding Behaviors*

	Yes	No
Does your child avoid or dislike bright lights, colors or busy pictures?
Does the child become very upset when bumped or pushed, even by accident?
Does the child get dizzy easily?
Does the child dislike when his/her feet leave the ground?
Does the child dislike tags in clothing, seams in socks, etc?
Is the child sensitive to certain types of fabrics in clothing and/or sheets?

Please elaborate on any of the selections made above:

The Child's Swimming Ability: Good, Poor, or Unknown*

Learning Disabliites? yes or no*

Please elaborate if you selected yes above:

Child's Reading Level:*

Please enter a numeric value corresponding to the grade level

Has the child attended Royal Family Kids before?*

Child’s Shoe Size

Child’s T-shirt Size:*

Youth S, M. L, or Adult S, M, L, XL, XXL

Camper Details: attach a separate sheet if needed*

	Explanation
Child's Favorite Snack
Child's Favorite Color
Child's Favorite Activity/Hobby
Any fears or triggers we need to be aware of?
If a child is throwing a tantrum, what is the best way to help them through it?
Birthday Gift Ideas
Favorite animal

Indicate all known allergies, illness, disabilities, physical limitations or complications:

Allergies or Dietary Restrictions (If none, type "none"):*

Illnesses/Medical Complications (If none, type "none"):*

Disabilities/Limitations (If none, type "none"):*

Indicate date of illness, severity, complications, and any residual impairments:*

	Date of Illness	Severity	Complications	Residual Impairments	None
Respiratory Problems
Heart or Circulation
Pulmonary Edema
Hay Fever
Balance Problems
Insect Bites
Hypoglycemia
Dizzy Spells
Back
Diabetes
Drug Allergy
Foot
Seizure Disorders
Poison Oak
Fainting
Anaphylactic Shock
Muscoluskeletal Allergies
Other

Please elaborate on any of the selections made above:

Any specific activities to be encouraged?

Any specific activities to be restricted?

Immunization History*

	Date
DTP Series
Booster
Tetanus Booster
Polio OPV (Sabin)
Typhoid
Measles Vaccine (live)
Tuberbulin (TB) Test
German Measles (Rubella)
Mumps Vaccine (live)
Smallpox
Not Vaccinated

Is your child taking medications? If yes, all medications must be in original packaging with pharmacy label on it. If not please mark the last box.*

	Name of Medication	Purpose	Dosage	Times
1
2
3
4
5
No medications

What is (are) the medication(s) used for:

Please add any other comments related to HEALTH and MEDICATIONS:

Doctor's Name: *

First NameLast Name

Doctor's Phone Number:*

Area CodePhone Number

I understand that it is my responsibility as caregiver to make sure that all instructions are clear and that the necessary dosage is adequately supplied for the duration of camp. I hereby authorize RFK's Camp nurse to administer the above medication from 8/5/2024-8/9/2024. *

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 be rendered under the general or special supervision of any physician 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, 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 as legal guardian/social worker/other. I give my permission for the above mentioned minor to attend Royal Family KIDS Camp in the summer of 2024through Living Water Church *

Above Signer's Relationship to child:*

Child's Medicaid #*

PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATIONS

I hereby give the Royal Family KIDS' Camp Registered Nurse permission to administer the following products according to manufacturer's instructions, or as otherwise specified.

I trust the RFK Camp Registered Nurse to use her best judgment as situations arise, and if in doubt, he/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.

Medications*

	Yes	No
Sunblock
Insect Repellent
Lip Blam
Rash Ointment
Tylenol
Antiseptic Ointment
Band-Aids
Anti-Itch Cream
Hydrogen Peroxide
Cough Syrup
Cough Drops
Decongestant
Antihistamine
Ipecac Syrup
Melatonin
Dramamine

Please list any over-the-counter medications NOT included in the list above allowed to be administered:

Please Upload a picture of the child's insurance card:*

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Name of Person Authorized to Pick Up Child:*

First NameLast Name

Phone Number of Person Authorized to Pick Up Child:*

Area CodePhone Number

Name of alternate Person or persons Authorized to Pick Up Child:

First NameLast Name

Phone Number of alternate Person Authorized to Pick Up Child:

Area CodePhone Number

Is there anything else you feel we should know about this child?

Parent or Legal Guardian's Signature*

PLEASE NO ELECTRONIC DEVICES, MONEY OR FOOD. THESE ITEMS ARE NOT NEEDED AT CAMP.

Camper Application

Camp Date: August 5th-9th, 2024 Application DEADLINE June 23rd