RFK Camper Registration 2020

DO NOT PRINT THIS APPLICATION...MUST BE FILLED OUT AND SUBMITTED ONLINE. THE APPLICATION WILL LIKELY TAKE 20-30 MINUTES TO COMPLETE. YOU WILL NEED TO ATTACH AN IMMUNIZATION RECORD AND A JPEG PHOTO OF THIS CHILD TO COMPLETE THE APPLICATION. ALL APPLICATIONS MUST BE RECEIVED BY APRIL 19th. YOU WILL HEAR BACK FROM US VIA EMAIL BY MAY 29th. All Campers must be between the ages of 7-11 at the time of camp: July 13-17, 2020 (there are a few exceptions to this). The drop-off/pick-up location is The Bridge (adjacent to Compass Christian Church), 824 W. Germann Rd Chandler, AZ 85286
Note: If you have an older child or these dates do not work for you please visit AZHOPE.COM for more camp dates. Please only register a child for ONE RFK Camp per summer. If they have attended RFK Camp before, we recommend they continue attending with that same sponsored camp if possible.
Questions?
If you have questions or concerns about RFKC Compass please contact our volunteer Child Placement Coordinator Margaret Garrett RFKCompass@azroyalfamily.com or Camp Director Jann'e Gutierrez at Janne@azroyalfamily.com.
Name of Person Filling Out This Application*
First NameLast Name
Relationship To Child*
Provider (foster parent)Group home staffParentCaseworkerOther (if other, please specify)
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*
MaleFemale
Birthdate*
MonthDayYear
Age at Time of Camp (July 13-17, 2020)*
6 years old7 years old8 years old9 years old10 years old11 years old
Emotional Age *
This child will be entering this grade in the fall of 2020.*
1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade
Child's T-Shirt Size (shirts run small)*
Child MediumChild LargeAdult MediumAdult LargeAdult XL
Shoe Size*
Is this child a returning RFK Camper? (Please only register a child for 1 RFK Camp per summer. If they have attended RFK Camp before, we recommend they continue attending with that same sponsored camp if possible)*
Yes, returning RFK CamperNo, not a returning RFK CamperDon't know if child has been to RFK Camp before
Are you interested in finding out how this child can be part of the RFK Mentoring Club throughout the 2020-2021 school year?*
Yes - Please send more information!Maybe - Please send more information!No, thank you
Siblings of Child Applying to RFK Camp This Summer
If siblings of this child will ALSO be applying to come to camp, please provide their information so we can try to get all siblings to camp this summer. A separate registration will need to be completed for each child.
If a sibling of this child is applying to camp, please tell us who that is.
First NameLast Name
This sibling is a...
Biological SiblingFoster SiblingGroup home siblingSibling in Adoptive Family
If 2nd sibling is applying to camp, please tell us who that is.
First NameLast Name
2nd sibling is a...
Biological SiblingFoster SiblingGroup home siblingSibling in Adoptive Family
If 3rd sibling is applying to camp, please tell us who that is.
First NameLast Name
3rd sibling is a...
Biological SiblingFoster SiblingGroup home siblingSibling in Adoptive Family
If 4th sibling is applying to camp, please tell us who that is.
First NameLast Name
4th sibling is a...
Biological SiblingFoster SiblingGroup home siblingSibling in Adoptive Family
Parent/Guardian Information
This home is best described as...*
Foster HomeGroup HomeAdoptive ParentsKinshipBiological Parent(s)Other
At time of camp, how long will this child have been living in current home?*
less than 4 months4-6 months6-12 months1-2 years2-3 years3-4 years4+ yearsOther
Total # foster or residential placements for child including current home*
Home Mailing Address (for camp correspondence)*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Parent or Guardian #1 (this person will receive the email auto-reply and future email correspondence regarding child) *
First NameLast Name
Relationship to Child*
Best Phone Number*
Area CodePhone Number
This phone is a:*
Cell PhoneWork PhoneHome Phone (land line)
Parent/Guardian #1 Email Address (if a group home please give group home manager's email)*
Parent or Guardian #2
First NameLast Name
Relationship to Child
Parent or Guardian #2 Best Phone Number
Area CodePhone Number
This phone is a:
Cell PhoneWork PhoneHome Phone (land line)
Parent/Guardian #2 Email Address
Authorized to Pick Child Up From Camp on Friday, July 17, 2020
Who is an authorized adult that may pick this child up after camp on July 17? **Government ID required***
First NameLast Name
Cell Number for Authorized Adult *
Area CodePhone Number
SECOND authorized adult. **Government ID required**
First NameLast Name
Cell Number For Authorized Adult
Area CodePhone Number
Caseworker/Child Placement Agency Information
Caseworker Name*
First NameLast Name
Caseworker Email*
Caseworker Phone 1*
Area CodePhone Number
Caseworker Phone 2
Area CodePhone Number
Caseworker's Supervisor
First NameLast Name
Supervisor Email
Supervisor Phone Number (not intake #)
Area CodePhone Number
Background/Behavior Information
Please fill this out to the best of your ability. All information shared is confidential. We as RFKC staff want to make sure this child as well as other campers have a safe, healthy, fun time at camp. This information is extremely helpful and is only shared with camp staff on a "need to know" basis.
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?*
Never wets the bedRarely wets the bedFrequently wets the bedWets the bed every nightDo not know about bed wetting
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?*
Never aggressiveRarely aggressiveFrequently aggressiveAlways AggressiveDo not know if child is aggressive
Please explain aggressive behavior. (What may trigger aggressive behavior or to whom child is aggressive.)
Does the child deal with any of the following eating disorders or issues around food?*
AnorexiaBulimiaOvereating/GorgingNo Eating DisordersDo Not Know Of Any Eating DisordersHording or Stealing FoodOther
If this child does have an eating disorder - or has other issues around food we should know about - please explain.
How would you describe this child's demeanor?*
Very calmSomewhat hyperactiveFrequently hyperactiveAlways hyperactiveDon't know about hyperactivity
Please let us know if any of the following learning difficulties exist for this child.
Hearing impairmentVision impairment (that would affect time at camp)Reading difficultiesDon't know about learning difficultiesOther
How often does this child lie?*
Never liesRarely liesFrequently liesAlways liesCan't tell lies from truthDon't know if this child has a habit of lying
Please let us know how often this child has night terrors.*
No night terrorsRarely has night terrorsFrequently has night terrorsDon't yet know about night terrors
Please let us know how often this child has nightmares.*
No nightmaresRarely has nightmaresFrequently has nightmaresDon't yet know about nightmares
Please let us know how to calm this child or prevent nightmares.
Please let us know how often this child runs away from a situation or from home.*
Never runs awayRarely runs awayFrequently runs awayAlways runs awayDon't yet know if child runs away
Please let us know if - or how - this child may act out sexually.*
Does not act out sexuallyDo not know if sexually acts outTouches selfTouches other childrenFlirts or pays inappropriate attention to adults
If this child does act out sexually, please explain.
How often does this child steal things?*
Never stealsRarely stealsFrequently stealsDo not know about stealing yetKnow of stealing in the past, but not currently
How often does this child have tantrums or anger issues?*
Does not have tantrums or anger issuesRarely has tantrums or anger issuesFrequently has tantrums or anger issuesDon't know about tantrums or anger yet.
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?*
Never withdrawnRarely withdrawnFrequently withdrawnDon't know about how often child withdraws yet
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 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!)
Medical History + Prescription Medication Information
REQUIRED: ATTACH A COPY OF CHILD'S IMMUNIZATION RECORD
List ALL known ALLERGIES to food, plants, medications, animals, etc. (If none, put N/A)*
This child's swimming ability is...*
Poor Swimming AbilityGood Swimming AbilityExcellent Swimming AbilityDo Not Know Swimming Ability
Illnesses and Medical Complications Past or Present (check all that apply)*
Respiratory ProblemsSeasonal AllergiesFood AllergiesMedicine AllergiesTopical Allergies (lotion, sunscreen, etc.)Dizzy Spells and/or FaintingBack ProblemsSeizure DisordersAnaphylactic ShockBalance ProblemsAsthmaADD or ADHDHypoglycemiaHeart or Circulation ProblemsPulmonary EdemaType 1 DiabetesType 2 DiabetesInsect Bite Allergies (i.e. mosquitoes, bees, etc.)Recent SurgeryRecent Broken BonesNONEOther
Please explain each medical issue you checked above. (If you did not check anything, please say DOES NOT APPLY."*
What, if any, specific activities should be DISCOURAGED for medical reasons while at camp?
NON-PRESCRIPTION Medications / Treatments: that you approve the medical team to administer at camp.*
Sunblock/SunscreenInsect RepellentLip BalmRash OintmentAcetaminophenIbuprofenAntiseptic OintmentBand-aidsAnti-Itch CreamHydrogen PeroxideRubbing AlcoholCough SyrupCough DropsDecongestantAntihistamineMelatoninOther
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, July 13 - Friday, July 17, 2020.) I authorize RFKC medical staff to administer the medications.*
Yes, I understand that sharing medical info, medications, and dosages are my responsibility.No, I do not understand that sharing medical info, medications, and dosages are my responsibility.
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.)
Side effects of the prescription drugs, vitamins, or over-the-counter medications sent to camp?
Additional information we need to know about the above prescription drugs, vitamins, or over-the-counter medications sent to camp - or - additional medications, if any.
Primary Doctor*
First NameLast Name
Doctor's Phone Number*
Area CodePhone Number
Please upload a recent photo of this child. 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
Permission
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: X-Ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care for the above minor, which 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 en-route to and from camp, 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. My permission is given for the minor named in this application to attend Royal Family KIDS Camp in the summer of 2020 through Compass Christian Church, 1825 S. Alma School Rd, Chandler, AZ 85286.
Name*
First NameLast Name
Date*
MonthDayYear
PERMISSION TO TRANSPORT:
The above-mentioned organizations, are hereby authorized to transport said minor by bus from the registration location in Chandler, AZ to the campground on July 13th, 2020, and transport the minor from the campground to the pick-up location in Chandler, AZ on Friday, July 17th, 2020. I understand that if I should, for any reason, desire to retrieve said minor from camp before Friday, July 17th, 2020, I will first be required to make arrangements with the directors and meet at an agreed upon location. By my signature, I release Compass Christian Church, Royal Family Kids Inc, and any other involved parties from liability in relation to travel to and from camp.
Name*
First NameLast Name
Date*
MonthDayYear
Enter the message as it's shown*
Should be Empty:

Questions?

Child's Information

Siblings of Child Applying to RFK Camp This Summer

Parent/Guardian Information

Authorized to Pick Child Up From Camp on Friday, July 17, 2020

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

Prescription & Over-the-Counter Medications

Permission

PERMISSION TO TRANSPORT: