______ Received ______ Voucher Y/N ______ Amount Paid ______ Med Form RETURN APPLICATION TO: ROYAL FAMILY KIDS’ CAMP 2014 (Boys and Girls Ages 7-11) The Stone Church Attn: Megan Doré 10737 W. Orland Pkwy Orland Park, IL 60467 Sponsored by: The Stone Church 10737 W. Orland Parkway Orland Park, IL 60467 ______ Accepted ______ Denied ______ Letter Sent ______ Confirmed (708) 385-2770 Ext. 7011 Fax: (708) 478-1445 June 23rd-27th 2014 Royalfamilykids17@gmail.com *ALL INFORMATION IS KEPT CONFIDENTIAL* CAMPER REGISTRATION FORM Instructions: Please Print. This form must be completely filled out. The information is vital to the health and well-being of the child. Your application will be returned to you if it is not completely filled in. A completed application does not mean that the child is automatically accepted into camp. Child’s Legal Name: _______________________________________________ Birthdate: _______________ Name to use at camp: _________________________ Sex: M F Next grade in school: ______ Level of Care: (Circle One) Age:_______ BASIC Emotional Age: _______ MODERATE SPECIALIZED CAMPER DETAILS: Number of Meds child takes:______ Height:_______ Weight:_______ Shoe Size:_______ Swimming ability: □ Good □ Poor □ Do not Know Permission to swim: □ Yes □ No Special Education Student in School: □ Yes □ No Reading Level: ___________ Behavior Plan or Special Needs that we need to be aware of for staffing: ____________________________ __________________________________________________________________________________________ Special Toileting Needs (Diaper, catheter, etc.): __________________________________________________________________________________________ What is their typical morning and nighttime routine? Is there anything we need to know that will help while at camp? (Showers, baths, special routines, safety plans, or privacy needs)____________________________________________________________________________________ T-Shirt Size: Child: □ Med □ Lrg OR Adult: □ Med □ Lrg □XL □2XL Has child attended a Royal Family Kids Camp before? □ Yes, where & when_____________________ □ No Child is currently living with: □ Group Home □ Foster Home □ Relative □ Mom/Dad □ Adoptive Mom/Dad How long has the child been in this home? ______ Time in foster care?______ Moved often? □ Yes □ No Separated from siblings? □ Yes □ No PARENT/GUARDIAN INFORMATION: Name: ______________________________________________ Home Phone: _________________________ Address: ____________________________________________ Cell Phone #1: ________________________ City, State, Zip: ______________________________________ Cell Phone #2: ________________________ Child’s Name:_______________________________ E-mail: _____________________________________________ Work Phone: _________________________ Social Worker/Caseworker: ___________________________ Phone: _______________________________ E-Mail Address:___________________________________ Cell Phone: _______________________________ EMERGENCY CONTACT: Name: ______________________________________________ Phone: ______________________________ CAMPERS EMOTIONAL/BEHAVIORAL HISTORY Often Aggressiveness Bedwetting Biting Eating Disorders Hyperactive Learning & Disabilities Lying Self Harm Behaviors Sometimes Never Often Night Terrors Nightmares Runs Away Sexual Acting Out Steals Tantrums Withdrawn Suicidal Thoughts Sometimes Never Details from above: ________________________________________________________________________________________ ________________________________________________________________________________________ Describe why this child was placed in Foster Care and any unusual family circumstance this child has experienced in the past (severe social or economic deprivation, physical abuse, sexual abuse, neglect, abandonment, recent stress, adopted, etc) that has had an impact on this child: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ What helps this child feel comfortable? (things they like to do) ________________________________________________________________________________________ What may cause this child to feel uncomfortable? ________________________________________________________________________________________ What triggers negative behavior? ________________________________________________________________________________________ What type of positive discipline is effective? ________________________________________________________________________________________ Page 2 of 5, Document1, 10/13 Child’s Name:_______________________________ Are there any signs that behavior is about to escalate, and what helps to de-escalate this child? ________________________________________________________________________________________ ________________________________________________________________________________________ HEALTH HISTORY: (Indicate all known allergies, illness, disabilities, physical limitations or medical complications) Allergies (Food or Environmental) ________________________________________________________________________________________ Illnesses/medical complications ________________________________________________________________________________________ Disabilities/Limitations ________________________________________________________________________________________ Leg or Arm Braces Hearing Aids Eating Disorder Yes Indicate date of illness, severity, complications, and any residual impairment. Respiratory Problems _____ Hypoglycemia _____ Musculoskeletal Allergies Heart or Circulation _____ Dizzy Spells _____ Foot Pulmonary Edema _____ Back _____ Seizure Disorders Hay Fever _____ Poison Oak _____ Anaphylactic Shock Balance Problems _____ Diabetes _____ Fainting Insect Bites _____ Drug Allergy _____ Other No _____ _____ _____ _____ _____ _____ Details from above: ________________________________________________________________________________________ ________________________________________________________________________________________ Any specific activities to be restricted? ________________________________________________________________________________________ IMMUNIZATION HISTORY: Please fill in dates of basic immunizations and most recent booster as best as you can. DTP Series _____ Booster _____ Tetanus Booster _____ Polio OPV (Sabin) _____ Typhoid _____ Measles Vaccine (live) _____ Tuberculin (TB) Test _____ German Measles (Rubella) _____ Mumps Vaccine (live) _____ Small Pox _____ PRESCRIPTION MEDICATIONS: ***All medication sent to camp must be in original container with the pharmacy label on it.*** Is your child taking any medications? No Yes If yes, please fill in the following: 1. Name: ____________________________________ Dosage: ____________Times:_________________ 2. Name: ____________________________________ Dosage: ____________Times:_________________ 3. Name: ____________________________________ Dosage: ____________Times:_________________ Page 3 of 5, Document1, 10/13 Child’s Name:_______________________________ What is the medication(s) for: ________________________________________________________________________________________ ________________________________________________________________________________________ Doctor's Name _________________________________________ Phone___________________________ Please add any other comments related to HEALTH and MEDICATIONS in the space below. The person signing below certifies that the information included in this application is correct. It is also understood that submittal of this application is simply a part of the application process. Royal Family Kids Camp #17 will notify you to let you know the status of your application. 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 RFKC’s nurse to administer the above medication from _________________ to _________________. Day/Date Day/Date _____________________________________ Parent or Legal Guardian Signature _________________________________ Printed Name ___________ Date ***If you have any questions about this form, or how to fill it out, please e-mail the camp or leave us a message with a phone number you can be reached at. Contact information is on the first page of the application.*** Page 4 of 5, Document1, 10/13 Child’s Name:_______________________________ 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 Stone Church Orland Park. Camper Year _________________________________________ 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. YES NO Specify if desired: Sunblock Insect repellant Lip balm Rash ointment Tylenol Antiseptic ointment Band-aids Anti-itch cream Hydrogen peroxide Cough syrup Cough drops Decongestant Antihistamine Iipecac syrup Other Other Other Other __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ Parent or Legal Guardian’s Signature: _________________________________________________ Printed Name: ______________________________ Phone numbers: __________________ Person(s) Authorized to pick-up child _____________________________ __________________ PLEASE NO CAMERAS OR MONEY. THESE ITEMS ARE NOT NEEDED AT CAMP. Page 5 of 5, Document1, 10/13