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Indicate all known allergies, illness, disabilities, physical limitations or medical complications:
All medication sent to camp must be in original labeled container with the pharmacy label on it.
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 Royal Family KIDS of Manhattan, KS Camp Nurse to administer the above medication from June 12th, 2017 to June 16th, 2017.
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 Family KIDS of Manhattan, KS 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 KIDS of Manhattan, KS as legal guardian/social worker/other. I give my permission for the child to attend Royal Family KIDS of Manhattan, KS Camp June 12th, 2017 to June 16th, 2017 through Manhattan First Assembly of God.
PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATIONS
I hereby give the Royal Family KIDS of Manhattan KS Camp Nurse permission to administer the following products according to manufacturer’s instructions, or as otherwise specified during the period of camp beginning June 12 and ending June 16, 2017.
I trust the RFK Camp 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.
This is the end of the Camp Application. We have a limit of 16 girls and 16 boys. We will contact you with your status soon. At that time, we will provide specific drop off and pick up times, along with a list of things to pack.
Please continue to click Next until you come to the end of the Mentoring Club Application. There is a Submit Button at the end of the Mentoring Club Application that will need to be clicked in order for the Camp Application to be submitted.
Mentoring Club is a school year program for our campers that allows your child to be paired with a mentor that commits to meeting with your child for 4 hours each month. Club is a once-a-month get together with other volunteers from camp and other mentors and campers. We have found it to be a wonderful addition to Camp.
YOU DO NOT NEED TO FILL OUT THE MENTORING CLUB APPLICATION IF YOU DO NOT WISH FOR YOUR CHILD TO PARTICIPATE.
Kids who have attended Royal Family KIDS Camp of Manhattan can apply for Mentoring Club. Mentoring Club provides fun times with their own matched adult mentor (trained and background checked) for 4 hours a month, plus once-a-month Club events during the school year on a Saturday morning. Approved mentors can help with transportation and there is no fee for participation. Club participation includes a backpack, club shirt and other club materials.
HOW TO APPLY: To have your child considered for this, please complete this application plus the following two permission forms (medical and transportation) and submit it with this application for Camp.
You will be contacted by the Mentoring Club Director later in the summer to discuss the match with a qualified mentor for your child during the next school year.
Please understand that the number of children matched and admitted is limited by the number of mentors available, and that age and geography are also limiting factors. As part of the matching process, the Camp application information will be shared with the Mentoring Director to best match your child with a qualified mentor.
As the undersigned legal parent or caregiver, I understand that the Medical section in the Camp Application will be shared with the Mentor and Mentoring Director.
This Medical Relase Form is effective on the date of my signature below and will remain in full force and effect as long as my child participates with Royal Family KIDS of Manhattan, KS Mentoring Club in any manner; it applies to any Club activities, events or functions, as well as individual meetings with a Club Mentor (the "Activities").
I hereby give permission for my child to attend and participate in the Activities. I specifically authorize Royal Family KIDS of Manhattan, KS Mentoring Club to provide for, and arrange in my place, necessary medical care.
I authorize the Royal Family KIDS of Manhattan, KS Mentoring Director or any designated adult, in whose care my child has been entrused, to arrange for and consent to any x-ray examination, anesthetic, and/or medical, surgical and dental procedure and treatment, and hospital care, to be rendered to my child under the general or special supervision, and on the advice of any physician or dentist duly licensed by an appropriate regulatory agency, or the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of such physician, dentist or hospital. The undersigned shall be liable and agree to pay all costs and expenses incurred in connection with such medical, dental and/or hospital services rendered to my child pursuant to this authorization. Should it be necessary for my child to be transported home or to medical facilities due to medical reasons or otherwise, the undersigned shall assume all transportation costs.
This Medical Release Form will be used only as necessary. Every reasonable effort will be made to first notify a caregiver listed below, or in this application, prior to the use of this Medical Release Form.
As the undersigned legal parent or caregiver or social services agent, I request that my child be allowed to participate in the Royal Family KIDS of Manhattan, KS Mentoring Club Program.
This Transportation and Activities Permission and Release Form is effective on the date of my signature below and will remain in full force and effect as long as my child participates with Royal Family KIDS of Manhattan, KS Mentoring Club in any manner; it applies to any Club activities, events or functions, as well as individual meetings with a Club Mentor (the "Activities").
I hereby give my permission for my child to ride in any vehicle designated by the adult(s) in whose care my child has been entrusted while participating in the Activities.
In consideration for permitting my child to attend and/or participate in the Activities, I do hereby release, and on behalf of my child release, Royal Family KIDS of Manhattan, KS Mentoring Club, the local Mentoring Club's mentors, leaders, volunteer assistants, the host church, and any designated driver of a van, bus, car, or other vehicle used in connection with any of the Activities ("Released Parties") from any and all claims for injuries, losses, damages, costs and expenses that I, and/or my child, might have against the Released Parties, arising out of, or in any way relating to, my child and the Activities, and I agree to hold the Released Parties harmless from any loss arising from such claims.
I certify that I have read, understand, and agree to the provisions of this Activities and Transportation Permission and Release Form, including the separate Medical Release Form included in this application.
Thank you so much for your application to Royal Family KID'S Camp - Manhattan, KS