Camper Application Camper Application Child’s Last Name(Required) First First Name(Required) First Preferred Name(Required) First SexMaleFemaleOtherBirthdate MM slash DD slash YYYY AgeCurrent Emotional AgeStreet City ZipSchool 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 PhoneEmergency ContactPhoneRelationship to Child Social Worker Day Phone NumberMoved 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 HISTORYAggressiveness 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all Sexual Acting Out Often Sometimes Not at all Steals Often Sometimes Not at all Tantrums Often Sometimes Not at all Withdrawn Often Sometimes Not at all Details from above: CAMPER DETAILS:This child's swimming ability is: Good Poor Do not Know Learning Disabilities: Yes No Reading Level: Has the child attended a Royal Family Kids Camp before? Yes No If Yes , where? Camper T-Shirt Size: Child Small Child Medium Child Large Adult Small Adult Medium Adult Large HEALTH HISTORYAllergies Illnesses/medical complications Disabilities/Limitations Leg or Arm Braces Hearing Aids Eating Disorder Yes No 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? No 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 MEDICATIONSI 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 No Specify if desired: Insect repellant Yes No Specify if desired: Lip balm Yes No Specify if desired: Rash ointment Yes No Specify if desired: Tylenol Yes No Specify if desired: Antiseptic ointment Yes No Specify if desired: Band-aids Yes No Specify if desired: Anti-itch cream Yes No Specify if desired: Hydrogen peroxide Yes No Specify if desired: Cough syrup Yes No Specify if desired: Cough drops Yes No Specify if desired: Decongestant Yes No Specify if desired: Antihistamine Yes No Specify if desired: Ipecac syrup Yes No Specify if desired: Other Yes No Specify if desired: Other Yes No Specify if desired: Other Yes No Specify if desired: Parent or Legal Guardian’s Signature:Printed Name: Phone numbers: Person Authorized to pick-up child NameThis field is for validation purposes and should be left unchanged.
