Royal Family Kids Application

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.

______

Child’s Last NameFirst NamePreferred NameSexBirthdate

______

StreetAge Current Emotional Age

______

CityZipSchoolGradeReading level

The child is living with: (Check one) Foster Parent Group Home Relative

______

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

_(______)______(______)______

Home Phone:Work Phone

______(______)______

Emergency ContactPhone

______

Relationship to Child

______(______)______

Social WorkerDay 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

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OftenSometimesNot at all

Aggressiveness

Bedwetting

Biting

Eating Disorders

Hyperactive

Learning & Disabilities

Lying

OftenSometimesNot at all

Night Terrors

Nightmares

Runs Away

Sexual Acting Out

Steals

Tantrums

Withdrawn

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Details from above:______

______

______

CAMPER DETAILS:

This child's swimming ability is: Good  Poor Do not Know

Learning Disabilities: Yes NoReading Level:______

Has the child attended a Royal Family Kids Camp before?  Yes, where?______ No

Camper T-Shirt Size:  Child Small  Child Medium  Child Large  Adult Small  Adult Medium  Adult Large

HEALTH HISTORY

Indicate all known allergies, illness, disabilities, physical limitations or medical complications:

Allergies ______

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:

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, please fill in the following

**Please Fill Out This Form in its Entirety. Do Not Leave Any Blank Spaces. Thank You.**

Does your child have any allergies to food or medications?______

______

What kind of allergic reaction do they have when this is taken?______

______

Does your child have any medical diagnoses?______

______

Has your child ever been hospitalized or have any medical conditions?______

______

Can your child receive the following over the counter remedies if needed? Please indicate yes or no.

Ibuprofen YES NO

Tylenol YES NO

Cold Medicine YES NO

Antihistamines YES NO

BenadrylYES NO

Pepto BismolYES NO

Bug Bite CreamYES NO

NeosporinYES NO

Eye DropsYES NO

Sunscreen YES NO

Bug RepellantYES NO

ChapstickYES NO

Is your child currently taking any medications, prescription or over the counter? YES NO

If so, please complete the following page.

All medications MUST be sent in original prescription bottles

Do not send in medication boxes Do not combine medications

Please include one additional dose of each medication in the event of dropped and/or contaminated medications

Please include and send over the counter medications your child takes regularly

**Please Fill Out This Form in its Entirety. Do Not Leave Any Blank Spaces. Thank You.**

Notify the Camp Personnel of Any Medication or Dose Changes Before Check-In

MEDICATION:______DOSE:______

INSTRUCTIONS: ______

ACTUAL TIME MEDICATION TAKEN:______

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MEDICATION:______DOSE:______

INSTRUCTIONS: ______

ACTUAL TIME MEDICATION TAKEN:______

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MEDICATION:______DOSE:______

INSTRUCTIONS: ______

ACTUAL TIME MEDICATION TAKEN:______

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MEDICATION:______DOSE:______

INSTRUCTIONS: ______

ACTUAL TIME MEDICATION TAKEN:______

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MEDICATION:______DOSE:______

INSTRUCTIONS: ______

ACTUAL TIME MEDICATION TAKEN:______

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MEDICATION:______DOSE:______

INSTRUCTIONS: ______

ACTUAL TIME MEDICATION TAKEN:______

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MEDICATION:______DOSE:______

INSTRUCTIONS: ______

ACTUAL TIME MEDICATION TAKEN:______

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MEDICATION:______DOSE:______

INSTRUCTIONS: ______

ACTUAL TIME MEDICATION TAKEN:______

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MEDICATION:______DOSE:______

INSTRUCTIONS: ______

ACTUAL TIME MEDICATION TAKEN:______

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

Doctor's Name______Phone______

Please add any other comments related to HEALTH and MEDICATIONS on an additional sheet.

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 SignaturePrinted NameDate

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 2011 through Scottsdale Bible Church. Camper

______

Authorized SignaturePrinted NameDate

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.

YESNOSpecify 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 Authorized to pick-up child ______

PLEASE NO CAMERAS OR MONEY. THESE ITEMS ARE NOT NEEDED AT CAMP.

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