Clone of 2017 RFK New Camper Application

Clone of 2017 RFK New Camper Application

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  • 2017 RFK New Camper Application

    Camp Dates : Monday June 12th, 2017 to Friday June 16th, 2017
  • Space is limited please return form as soon as possible!


  •  -  - Pick a Date

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  •   Often Sometimes Not at All
    Runs Away
    Sexual Acting Out


    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.

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  • 0/1000

    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 RFK’s 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 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 the child to attend Royal Family KIDS Camp June 12th, 2017 to June 16th, 2017 through Great Lakes Church.


    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 RFK Camp 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
    Acetaminophen (Tylenol) 325mg tabs
    Acetaminophen Liquid (Tylenol) 160mg/5ml
    Ibuprofen (Advil) 200mg tabs
    Ibuprofen Liquid (Advil) 100mg/5ml
    Diphenhydramine (Benadryl) 25mg tabs
    Diphenhydramine Liquid (Benadryl) 12.5mg/5ml
    Dextromethorphan (Delsym)15mg/5ml
    Calcium carbonate chewable (TUMS)
    Cough Drops (generic)
    Phenol spray (Chloraseptic spray)
    Triple antibiotic ointment (neosporin)
    Hydrocortisone cream 1%
    Hydrogen Peroxide OTC
    Solarcaine topical
    Pepto Bismal liquid and chewables
    Calamine or Caladryl Lotion
    Lice treatment/shampoo
    Bactine (first aid /antiseptic/pain reliever
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  • Thank you so much for your application to Royal Family KID'S Camp  - Kenosha.

    Space is limited and we will review your application and contact you within 2 weeks regardless of  acceptance. At that time, we will provide specific drop off and pick up times, along with a list of things to pack.

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