RFK Camper Application 2021

Return Completed Application to:

Royal Family Kids

5700 SW Dosch Rd

Portland, OR 97239

Instructions: This form must be completed prior to submission. Your application will not be accepted if there is any missing information. This information is vital to the health and well-being of the child.

New Campers: Please upload a photo of the camper or mail the photo to the address listed above.

Please indicate either NEW camper or RETURNING camper. *

Choose either NEW or RETURNING.

Please upload a current photo if applicant is a NEW Camper.

Browse Files

Camper's Name *

First Name Last Name

Camper's Birthdate *

Date

Current Emotional Age *

Camper's Sex *

Either M or F

Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Camper's School and Grade Level *

Parent / Legal Guardian's Name *

First Name Last Name

Relationship to Camper *

Email Address *

example@example.com

Primary Phone Number *

Area Code Phone Number

Alternate Phone Number *

Area Code Phone Number

Emergency Contact *

First Name Last Name

Emergency Contact Relationship to Camper *

Emergency Contact Phone Number *

Area Code Phone Number

Social Worker *

First Name Last Name

Social Worker Phone Number *

Area Code Phone Number

Please list number of siblings in foster care and their ages. If any of the siblings are applying to camp this year, please indicate. *

Camper was moved in Foster Placement how many times? How many moves within the last year? *

Would you like to receive a phone call from the RFK Camp Behavior Specialist prior to camp? *

Please explain any unusual family circumstances that make camp especially important for this child: (For example: recent crisis, special needs, recent transition back to family, etc.) This information helps us to better understand your child and their needs as we strive to find ways to support them for what they have been through. *

Camper Success: At RFK Camp we would like to be able to support your child to ensure they enjoy a successful week at camp. It is very helpful for us to know a few details regarding their behavior, interests and challenges. Please be as specific and complete as possible in considering the following areas.

What are the camper's greatest strengths or qualities? *

How does the camper interact with peers? *

What special interests does the camper have? *

How does the camper express fear, anxiety, confusion or anger? *

What techniques can we use to comfort the camper? *

Does the camper have any issues with self-abuse or aggression toward others? If yes, please describe. *

What sort of circumstances would cause the camper to run away from the group? *

Any additional information you believe would be helpful in providing a successful experience for the camper? *

Behavior Summary *

Often

Sometimes

Never

Aggressiveness

Bedwetting

Biting

Hyperactive

Lying

NIght Terrors

Nightmares

Runs Away

Sexually Acting Out

Steals

Tantrums

Withdrawn

Camper Details:

All Campers will be required to pass a Swim Test to use the rope swing, water slide or swim in the deeper end of the lake. Please indicate your child's swimming ability. *

Camper T-Shirt Size *

Camper Shoe Size *

Please indicate either Child Shoe Size or Adult Shoe Size.

Camper Health History: Please indicate all known food/environmental allergies, illnesses, disabilities, physical limitations or medical complications.

Food/Environmental Allergies: *

Illnesses/Medical Complications: *

Disabilities/Physical Limitations: *

Health Concerns:

Date

Severity

Impairment

Respiratory Problems

Heart or Circulation

Pulmonary Edema

Hay Fever

Balance Problems

Insect Bites

Leg or Arm Braces

Hypoglycemia

Dizzy Spells

Back

Anaphylactic Shock

Diabetes

Drug Allergy

Hearing Aids

Musculoskeletal Allergies

Foot

Seizure Disorders

Poison Oak

Fainting

Eating Disorder

Other

Immunization: Are immunizations up to date? *

Date of last Tetanus shot: *

Date

Prescription Medications: All medication sent to camp must be in the original container with the pharmacy label on it.

Is your child taking any medications? *

If yes, please fill in the following information.

Medication Name

Dosage

Times Given

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Doctor's Name and Phone Number *

Is your child allergic to any medications? *

If yes, please list below. *

Over-the-Counter Medications: Please give permission to use the medications listed below by indicating YES or NO for each one listed. This form must be completed by the primary caregiver who signs below.

Over-the-Counter Medication Permissions: *

YES

NO

Acetaminophen (Tylenol)

Ibuprofen (Advil)

Cough Syrup/Drops

Decongestant (stuffy nose)

Anti-histamine (allergy)

Antibiotic Ointment

Tums

Anti-Diarrhea

Hydrocortisone 1% Cream

Anti-Itch Cream

Would you like a phone call from the RFK Camp Nurse prior to camp? *

Please add any other comments related to HEALTH and MEDICATIONS below. *

Medical Permissions:

Prescription Medication - 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 nurse to administer the above listed prescription medication for the date range indicated below.

Over-the-Counter Medication - I hereby give the RFK's nurse permission to administer the above listed over-the-counter products according to manufacturer's instructions, or as otherwise specified. I trust the RFK nurse to use his/her best judgment as situations arise, and if in doubt, he/she can call for verification.

Medical Release - 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. This 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, dentist, at a hospital, camp or elsewhere. This authorization will remain effective while the above-minor is en route 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-named applicant/camper to attend Royal Family Kids' Camp and receive medication and medical treatment as provided above.

Date Range for adminstration of Prescription Medication: *

Please list to and from dates for prescription medication administration by RFK's nurse (Must include camp dates).

Child's Medicaid # / Health Insurance # *

Parent / Legal Guardian Signature *

First Name Last Name

Primary Phone Number *

Area Code Phone Number

Alternate Phone Number *

Area Code Phone Number

Authorized Pick-Up Individuals: Please list below the individuals that are authorized to pick up the camper. *

Emergency Contacts: In the unlikely event of an emergency, RFK will first try to contact the listed Parent or Legal Guardian, followed by the Emergency Contact and finally the Social Worker for the camper.

Date Submitted *

Date

Signature *

Clear