RFKC NWIA Camper Application 2018

RFKC NWIA Camper Application 2018

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  • Camper Application 2018

    Summer camp for foster children ages 6-12 | Sponsored by Bridge of Hope Ministries | 43 2nd Street NE | Sioux Center | IA | 51247 | 712-463-2643 | August 6 - 10, 2018
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  •   Often Sometimes Not At All
    Agressiveness
    Bedwetting
    Biting
    Eating Disorder
    Hyperactive
    Learning Disabilites
    Nightmares
    Night Terrors
    Runs Away
    Sexually Acting Out
    Steals
    Tantrums
    Lying
    Withdrawn
  •   Yes No
    Does the child create a lot of noise?
    Does the child crave bright lights, colors or busy pictures?
    Does the child like to crash into walls, people, etc.?
    Does the child use a lot of force when touching, hugging or with high fives?
    Does the child stomp feet when walking or kick feet when sitting?
    Does the child like to be under heavy blankets to sleep?
    Does the child love to spin or swing?
    Does the child like to hang upside down?
    Is the child unaware of messiness or hands or face?
    Does the child like to get dirty?
    Does the child like bare feet?
  •   Yes No
    Does your child avoid or dislike bright lights, colors or busy pictures?
    Does the child dislike heavy backpacks or heavy blankets?
    Does the child become very upset when bumped or pushed, even by accident?
    Does the child dislike spinning or doing somersaults?
    Does the child get dizzy easily?
    Does the child dislike being upside down?
    Does the child dislike being picked up or moved?
    Does the child dislike when his/her feet leave the ground?
    Does the child wipe kisses off cheeks?
    Does the child dislike tags in clothing, seams in socks, etc?
    Is the child sensitive to certain types of fabrics in clothing and/or sheets?
  •   Explanation
    Child's Favorite Snack
    Child's Favorite Color
    Child's Favorite Activity/Hobby
    Any fears or triggers we need to be aware of?
    If a child is throwing a tantrum, what is the best way to help them through it?
  • Indicate all known allergies, illness, disabilities, physical limitations or complications:

  •   Date of Illness Severity Complications Residual Impairments None
    Respiratory Problems
    Heart or Circulation
    Pulmonary Edema
    Hay Fever
    Balance Problems
    Insect Bites
    Hypoglycemia
    Dizzy Spells
    Back
    Diabetes
    Drug Allergy
    Foot
    Seizure Disorders
    Poison Oak
    Fainting
    Anaphylactic Shock
    Muscoluskeletal Allergies
    Other
  •   Date
    DTP Series
    Booster
    Tetanus Booster
    Polio OPV (Sabin)
    Typhoid
    Measles Vaccine (live)
    Tuberbulin (TB) Test
    German Measles (Rubella)
    Mumps Vaccine (live)
    Smallpox
    Not Vaccinated
  •   Name of Medication Purpose Dosage Times
    1
    2
    3
    4
    5
    No medications
  •  -
  • Clear
  • Clear
  • 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 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
    Sunblock
    Insect Repellent
    Lip Blam
    Rash Ointment
    Tylenol
    Antiseptic Ointment
    Band-Aids
    Anti-Itch Cream
    Hydrogen Peroxide
    Cough Syrup
    Cough Drops
    Decongestant
    Antihistamine
    Ipecac Syrup
  •  -
  • Clear
  • PLEASE NO ELECTRONIC DEVICES, MONEY OR FOOD. THESE ITEMS ARE NOT NEEDED AT CAMP.

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  • Should be Empty: