______ 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?
________________________________________________________________________________________
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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