Camper Application

Child’s Last Name(Required)

First

First Name(Required)

First

Preferred Name(Required)

First

Sex

Birthdate

MM slash DD slash YYYY

Age

Current Emotional Age

Street

City

Zip

School

Grade

Reading level

The child is living with: (Check one)

Foster Parent

Group Home

Relative

Name(s) of person(s) the child is living with

Email(Required)

Home Phone:

Work Phone

Emergency Contact

Phone

Relationship to Child

Social Worker

Day Phone Number

Moved in Foster Placement how many times?

Explain any unusual family circumstances that make camp especially important for the child:

(for example: recent crisis, being moved in foster placement, severe economic needs, etc.)

CAMPERS EMOTIONAL/BEHAVIORAL HISTORY

Aggressiveness

Often

Sometimes

Not at all

Bedwetting

Often

Sometimes

Not at all

Biting

Often

Sometimes

Not at all

Eating Disorders

Often

Sometimes

Not at all

Hyperactive

Often

Sometimes

Not at all

Learning & Disability

Often

Sometimes

Not at all

Lying

Often

Sometimes

Not at all

Night Terrors

Often

Sometimes

Not at all

Nightmares

Often

Sometimes

Not at all

Runs Away

Often

Sometimes

Not at all

Sexual Acting Out

Often

Sometimes

Not at all

Steals

Often

Sometimes

Not at all

Tantrums

Often

Sometimes

Not at all

Withdrawn

Often

Sometimes

Not at all

Details from above:

CAMPER DETAILS:

This child's swimming ability is:

Good

Poor

Do not Know

Learning Disabilities:

Yes

Reading Level:

Has the child attended a Royal Family Kids Camp before?

Yes

If Yes , where?

Camper T-Shirt Size:

Child Small

Child Medium

Child Large

Adult Small

Adult Medium

Adult Large

HEALTH HISTORY

Allergies

Illnesses/medical complications

Disabilities/Limitations

Leg or Arm Braces

Hearing Aids

Eating Disorder

Yes

Indicate date of illness, severity, complications, and any residual impairments.

Respiratory Problems

Hypoglycemia

Musculoskeletal Allergies

Heart or Circulation

Dizzy Spells

Foot

Pulmonary Edema

Back

Seizure Disorders

Hay Fever

Anaphylactic Shock

Poison Oak

Balance Problems

Diabetes

Fainting

Insect Bites

Drug Allergy

Other

Details from above:

Any specific activities to be encouraged?

Any specific activities to be restricted?

IMMUNIZATION HISTORY:

DTP Series

Booster

Tetanus Booster

Polio OPV (Sabin)

Typhoid

Measles Vaccine (live)

Tuberculin (TB) Test

German Measles (Rubella)

Mumps Vaccine (live)

Smallpox

PRESCRIPTION MEDICATIONS:

Is your child taking any medications?

Yes, please fill in the following.

Name:

Dosage:

Times:

Name:

Dosage:

Times:

Name:

Dosage:

Times:

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

Doctor's Name

Phone

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 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, 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 as legal guardian/social worker/other. I give my permission for __________________ to attend Royal Family Kids’ Camp in the summer of _ through [church name].

Authorized Signature

Printed Name

Date

Child’s Medicaid #

Signature:

Relationship to child:

Date

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 RFKC 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.

Sunblock

Yes

Specify if desired:

Insect repellant

Yes

Specify if desired:

Lip balm

Yes

Specify if desired:

Rash ointment

Yes

Specify if desired:

Tylenol

Yes

Specify if desired:

Antiseptic ointment

Yes

Specify if desired:

Band-aids

Yes

Specify if desired:

Anti-itch cream

Yes

Specify if desired:

Hydrogen peroxide

Yes

Specify if desired:

Cough syrup

Yes

Specify if desired:

Cough drops

Yes

Specify if desired:

Decongestant

Yes

Specify if desired:

Antihistamine

Yes

Specify if desired:

Ipecac syrup

Yes

Specify if desired:

Other

Yes

Specify if desired:

Other

Yes

Specify if desired:

Other

Yes

Specify if desired:

Parent or Legal Guardian’s Signature:

Printed Name:

Phone numbers:

Person Authorized to pick-up child

Name

This field is for validation purposes and should be left unchanged.