Kids Summer Camp Registration Form

IMPORTANT: We have 2 spots for boys & 2 for girls, but are starting a waitlist of children. Priority will be given to RETURNING RFKC Colorado Springs CAMPERS and KIDS CURRENTLY IN FOSTER CARE in El Paso County.
DO NOT PRINT THIS APPLICATION...MUST BE FILLED OUT AND SUBMITTED ONLINE. PRINTED APPLICATIONS WILL NOT BE ACCEPTED.
** PLEASE DO NOT APPLY FOR A CHILD WHO WILL BE 13 BY JUNE 22-26.**
IF YOU HAVE QUESTIONS about this application, about required paperwork, other need DHS assistance: Please contact our DHS Liaison Lynn Schulz at 719.444.5722 or dianaschulz@elpasoco.com
IF YOU HAVE QUESTIONS about available space, if your child qualifies for camp, or have other questions or concerns about RFKC: Please contact the RFK Child Placement Coordinator Melissa Tenpas at melissa.tenpas@dreamcenterscos.org
HAVE AN ADOPTED CHILD? If a returning RFK camper has been adopted since last year's camp, they are still allowed to attend camp with us. If they have NOT attended camp and are adopted, we will consider taking them to camp with us if we are not able to fill camp with foster children from El Paso County or Unaccompanied Refugee Minors (URMs).
TIME TO FILL OUT APP: Will take 30-40 minutes. Please fill out ENTIRELY. One application per child. Fill out and submit ONLINE ONLY. **DO NOT PRINT AND SCAN.** If you do not have Internet access - please find someone to help you fill this out online. If you're worried about your computer crashing or the app not going through, save answers as you go along in a Word Document and copy and paste into the application.
CURRENT PHOTO: You will be required to upload a current JPG photo of this child at the end of the app.
APPLICATION/REGISTRATION FEE: Camp only costs $25/child. {We raise and cover the additional $475 per child to send them to camp.) However, there are fees with processing each child for camp. The $25 is due at the time of application. You may pay with cash, check, or money order. CHECKS AND MONEY ORDERS SHOULD BE MADE OUT TO ROYAL FAMILY KIDS (Do NOT make them out to DHS.) Mail or hand in to: D. Lynn Schulz / Operations, Project Admin Coordinator / Citizens Service Center / 1675 Garden of the Gods Rd., 3rd Floor / Colorado Springs, CO 80907
APPLICATION DUE MONDAY, MAY 11, 2015 ** DO NOT PRINT THIS APPLICATION...MUST BE FILLED OUT AND SUBMITTED ONLINE **
Name of Person Filling Out This Application
First NameLast Name
Relationship To Child
Other
Child's Information
Child's Name
First NameLast Name
Preferred Name (if child has one)
If child is a returning Royal Family KIDS camper and had a DIFFERENT NAME LAST year, please let us know!
First NameLast Name
Gender
Birthdate
MonthDayYear
Age at Time of Camp (June 22-26)
Emotional Age
This child will be entering this grade in the fall of 2015.
Child's T-Shirt Size
Is this child a returning RFK Camper?
If yes, what year, city, and state?
Are you interested in finding out how this child can be part of the RFK Club & Mentors Program throughout the 2015-2016 school year?
Siblings of Child Applying to RFKC This Summer
If siblings of this child will ALSO be applying to the Colorado Springs RFKC camp, please provide their info so we can try and get all siblings to camp this summer.
If a sibling of this child is applying to camp, please tell us who that is.
First NameLast Name
This sibling is a...
If 2nd sibling is applying to camp, please tell us who that is.
First NameLast Name
2nd sibling is a...
If 3rd sibling is applying to camp, please tell us who that is.
First NameLast Name
3rd sibling is a...
If 4th sibling is applying to camp, please tell us who that is.
First NameLast Name
4th sibling is a...
Parent/Guardian Information
This home is best described as...
Other
If this child was adopted, when did you adopt him or her?
MonthDayYear
At time of camp, how long will this child have been living in current home?
Other
Approximately when was this child placed in the current home?
MonthDayYear
Total # foster or residential placements for child including current home.
Mailing Address (for camp correspondence)
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Parent or Legal Guardian #1
First NameLast Name
Relationship to Child
Best Phone Number
Area CodePhone Number
This phone is a:
Parent/Guardian #1 Email Address
Parent/Guardian #1 Second Email Address (if you have one)
Parent or Legal Guardian #2
First NameLast Name
Relationship to Child
Parent or Legal Guardian #2 Best Phone Number
Area CodePhone Number
This phone is a:
Parent/Guardian Two Email Address
Authorized to Pick Child Up at New Life on Friday, June 26
Who is the authorized adult that will be picking this child up from New Life after camp June 26. **Government ID required**
First NameLast Name
Cell Number for Authorized Adult #1
Area CodePhone Number
SECOND adult authorized to pick up this child from New Life June 26. **Government ID required**
First NameLast Name
Cell Number For Authorized Adult #2
Area CodePhone Number
Caseworker/Child Placement Agency Information
Child Placement Agency (Current or Past if Child Has Been Adopted)
Caseworker Name
First NameLast Name
Caseworker Email
Caseworker Phone 1
Area CodePhone Number
Caseworker Phone 2
Area CodePhone Number
CASA (Court Appointed Special Advocate) if child has one
First NameLast Name
CASA Email
CASA Phone Number
Area CodePhone Number
Background/Behavior Information
Please fill this out to the best of your ability. We as RFKC staff want to make sure your child has a safe, healthy, fun time at camp. This information is extremely helpful!
Why would this child's attendance at RFKC be important? Why would you like to see him or her attend camp?
How often does this child wet the bed at night?
If child does wet the bed, please explain (i.e. wears pull-ups, don't drink liquids after certain time, just need to be aware, etc.)
Does this child display aggressive behavior?
Please explain aggressive behavior. (What may trigger aggressive behavior or to whom child is aggressive.)
Does this child bite other children or adults?
Does the child deal with any of the following eating disorders or issues around food?
Other
If this child does have an eating disorder - or has other issues around food we should know about - please explain.
How often has this child start (non-campfire) fires?
If this child has set fires, please explain.
How would you describe this child's hyperactivity?
How would you describe this attention span?
Please let us know if any of the following learning difficulties exist for this child.
Other
If these learning difficulties will negatively affect this camper's week at camp - or if this information would help Big Campers & Staff make camp better for your child - please explain.
How often does your child lie?
If this child does have a habit of lying, please explain.
Please let us know how often your child has night terrors.
Please let us know how to calm your child or prevent night terrors.
Please let us know how often your child has nightmares.
Please let us know how to calm your child or prevent nightmares.
Please let us know how often this child runs away from a situation or from home.
If this child does run away, please explain what calms him or her down or what triggers running away.
Please let us know if - or how - this child may act out sexually.
If this child does act out sexually, please explain.
How often does this child steal things?
If this child does steal or take things, please explain.
How often does this child have tantrums or anger issues?
If this child does have tantrums or anger issues that are beyond normal childhood frustrations, please explain so we know how to redirect or prevent outbursts.
How often does this child withdraw?
If this child is withdrawn (or certain circumstances cause this), please explain.
HISTORY/STORY: Please share this child's history or story so we can understand how to give him or her an even MORE amazing week at camp!
** Please tell us about this child's history or story. What situations may have been challenging for this child before living in your home? What circumstances is this child dealing with?
If this child attended Royal Family KIDS' Camp in the past, what did he or she like about it? What positive changes or behaviors did you see upon their return home?
Please let us know strengths and great, positive things about this child. Please write as much as you'd like!
Please tell us what this child's interests, passions, loves, etc. are so our Staff can make camp even more special! (i.e. Loves sports, interested in horses, favorite color is purple...whatever!)
Any additional information you need for our staff or counselors to know while your child is up at camp?
Medical History + Prescription Medication Information
REQUIRED: Send a copy of child's Medicaid Card (or Insurance) + latest physical to: D. Lynn Schulz / Operations, Project Admin Coordinator / Citizens Service Center / 1675 Garden of the Gods Rd. 3rd Fl / Colorado Springs, CO 80907. (** If you do not have a copy of the child's Medicaid card, please call Lynn Schulz at 719.444.5722.)
List all known allergies to food, plants, medications, animals, etc.
Date of Last Physical
MonthDayYear
This child's swimming ability is...
What specific activities should we encourage your child to try while at camp?
Illnesses and Medical Complications Past or Present (check all that apply)
Other
Please explain each medical issue you checked above. (If you did not check anything, please say DOES NOT APPLY."
** Only check Medications that are NOT APPROVED**. The bus ride to camp is 2.5 hours through winding mountain roads, so please be aware that motion sickness is a good possibility.
What specific activities should be DISCOURAGED for medical reasons while at camp?
NON-APPROVED Medications / Treatments: Check ONLY those you DO NOT WANT the medical team to administer. Please refrain from the following...
Other
Please explain why you said NO to the medications you checked above. (If you did not check any, just say DOES NOT APPLY.)
Prescription & Over-the-Counter Medications
If your child is NOT taking any prescription or over-the-counter medications, vitamins, or inhalers to camp, please type "NONE" in each of the boxes.
I understand that it is my responsibility as a caregiver to make sure that all instructions are clear and that the necessary dosage is adequately supplied for the duration of camp (Monday, June 22, 2015, to Friday, June 26, 2015.) I authorize RFKC medical staff to administer the medications.
Prescription or Over-the-Counter Medication #1
Prescription Medication 1: Reason for taking, DOSAGE, and Time(s) of Day to Administer
How long as child been taking Medication 1? (Be specific.)
Prescription or Over-the-Counter Medication #2
Medication 2: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
How long has child been taking Medication #2? (Be specific.)
Prescription or Over-the-Counter Medication #3
Medication 3: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
How long as child been taking Medication #3? (Be specific.)
Prescription or Over-the-Counter Medication #4
Medication #4: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
How long as child been taking Medication #4? (Be specific.)
Prescription or Over-the-Counter Medication #5
Medication #5: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
How long has child been taking Medication #5? (Be specific.)
Additional information we need to know about the above prescription drugs, vitamins, or over-the-counter medications sent to camp - or - additional meds if any.
Physician, PA, or NP for Child
First NameLast Name
Physician, PA, NP, or Clinic Phone Number
Area CodePhone Number
IMMUNIZATIONS: Check immunizations that are NOT UP TO DATE to the best of your ability.
Other
If you checked any of the above immunizations saying this child has NOT RECEIVE THEM OR IS NOT UP TO DATE please explain...
**REQUIRED**: Recent Color Photograph ** JPG ONLY...do NOT upload a PDF or other file type **
Please upload a recent color photo of this child (within the last six months). Upload a JPG ONLY...do NOT upload a PDF or other file type **. You will not be able to upload a photo larger than 1 MB (or 1024 KB) in size.
Upload a File
Cancelof
After you have submitted this application, print the RFK Release Forms (6-page PDF) found at the link below. ** Please obtain the proper legal guardian or parent signatures for the forms. ** We cannot accept photocopies. We need paperwork with original signatures!
Please download the 6-page PDF Release Form for RFK here. Be sure to send all four pages back with ORIGINAL signatures. A photocopy of the pages will NOT be accepted.
APPLICATION CHECKLIST
Checklist for this Online Application: Check that you have ALL items needed to complete this application.
Enter the message as it's shown
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IMPORTANT: We have 2 spots for boys & 2 for girls, but are starting a waitlist of children. Priority will be given to RETURNING RFKC Colorado Springs CAMPERS and KIDS CURRENTLY IN FOSTER CARE in El Paso County.

DO NOT PRINT THIS APPLICATION...MUST BE FILLED OUT AND SUBMITTED ONLINE. PRINTED APPLICATIONS WILL NOT BE ACCEPTED.

APPLICATION DUE MONDAY, MAY 11, 2015 DO NOT PRINT THIS APPLICATION...MUST BE FILLED OUT AND SUBMITTED ONLINE

Child's Information

Siblings of Child Applying to RFKC This Summer

Parent/Guardian Information

Authorized to Pick Child Up at New Life on Friday, June 26

Caseworker/Child Placement Agency Information

Background/Behavior Information

HISTORY/STORY: Please share this child's history or story so we can understand how to give him or her an even MORE amazing week at camp!

Medical History + Prescription Medication Information

Only check Medications that are NOT APPROVED. The bus ride to camp is 2.5 hours through winding mountain roads, so please be aware that motion sickness is a good possibility.

Prescription & Over-the-Counter Medications

REQUIRED: Recent Color Photograph JPG ONLY...do NOT upload a PDF or other file type

After you have submitted this application, print the RFK Release Forms (6-page PDF) found at the link below. Please obtain the proper legal guardian or parent signatures for the forms. We cannot accept photocopies. We need paperwork with original signatures!

APPLICATION CHECKLIST

IMPORTANT: We have 2 spots for boys & 2 for girls, but are starting a waitlist of children. Priority will be given to RETURNING RFKC Colorado Springs CAMPERS and KIDS CURRENTLY IN FOSTER CARE in El Paso County.

DO NOT PRINT THIS APPLICATION...MUST BE FILLED OUT AND SUBMITTED ONLINE. PRINTED APPLICATIONS WILL NOT BE ACCEPTED.

APPLICATION DUE MONDAY, MAY 11, 2015 ** DO NOT PRINT THIS APPLICATION...MUST BE FILLED OUT AND SUBMITTED ONLINE **

Child's Information

Siblings of Child Applying to RFKC This Summer

Parent/Guardian Information

Authorized to Pick Child Up at New Life on Friday, June 26

Caseworker/Child Placement Agency Information

Background/Behavior Information

HISTORY/STORY: Please share this child's history or story so we can understand how to give him or her an even MORE amazing week at camp!

Medical History + Prescription Medication Information

** Only check Medications that are NOT APPROVED**. The bus ride to camp is 2.5 hours through winding mountain roads, so please be aware that motion sickness is a good possibility.

Prescription & Over-the-Counter Medications

**REQUIRED**: Recent Color Photograph ** JPG ONLY...do NOT upload a PDF or other file type **

After you have submitted this application, print the RFK Release Forms (6-page PDF) found at the link below. ** Please obtain the proper legal guardian or parent signatures for the forms. ** We cannot accept photocopies. We need paperwork with original signatures!

APPLICATION CHECKLIST

APPLICATION DUE MONDAY, MAY 11, 2015 DO NOT PRINT THIS APPLICATION...MUST BE FILLED OUT AND SUBMITTED ONLINE

Only check Medications that are NOT APPROVED. The bus ride to camp is 2.5 hours through winding mountain roads, so please be aware that motion sickness is a good possibility.

REQUIRED: Recent Color Photograph JPG ONLY...do NOT upload a PDF or other file type

After you have submitted this application, print the RFK Release Forms (6-page PDF) found at the link below. Please obtain the proper legal guardian or parent signatures for the forms. We cannot accept photocopies. We need paperwork with original signatures!