Royal Family Kids Camp

June 30 - July 4, 2025

The Royal Family Kids Camp is for foster children who would normally never have the opportunity to go to camp. Please fill out this form to register your camper if their caseworker has already been communicated with and agrees that the Royal Family Kids Camp will be a good option for them.

Camper Registration Form

Camper Registration PDF

YOUR INFORMATION

Your Last Name

Your First Name

Relationship to Child

Your Phone

BASIC CAMPER'S INFORMATION

Camper's Last Name

Camper's First Name

Camper's Preferred Name

Camper's Birthday

Camper's Sex

Male

Female

Camper's Current Address

The Camper is Living With:

Foster Parent

Group Home

Relative

Camper's Emotional Age

Name(s) of Person(s) the Camper Lives With:

Emergency Contact Name

Emergency Contact Phone

Social Worker's Name

Social Worker's Phone

How Many Times Has the Child Been Moved in Foster Placement?

Please explain any unusual family circumstances that make camp especially important for the child, for example: recent crisis, being moved in foster placement, severe economic needs, etc.

Upload a Clear Picture of the Camper

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CAMPER'S EMOTIONAL/BEHAVIORAL HISTORY

Aggressiveness

Often

Sometimes

Not At All

Night Terrors

Often

Sometimes

Not At All

Bedwetting

Often

Sometimes

Not At All

Nightmares

Often

Sometimes

Not At All

Biting

Often

Sometimes

Not At All

Runs Away

Often

Sometimes

Not At All

Eating Disorders

Often

Sometimes

Not At All

Sexual Acting Out

Often

Sometimes

Not At All

Hyperactive

Often

Sometimes

Not At All

Steals

Often

Sometimes

Not At All

Learning Disabilities

Often

Sometimes

Not At All

Tantrums

Often

Sometimes

Not At All

Lying

Often

Sometimes

Not At All

Withdrawn

Often

Sometimes

Not At All

Please explain the results from the Camper’s Emotional and Behavioral History from the previous section.

Does the Camper have a "Care Precaution Plan?"

Yes

CAMPER'S DETAILS

Camper's Swimmig Ability

Good

Poor

Do Not Know

Camper Has Learning Disability

Yes

Camper's Reading Level

Has the Camper Attended a Royal Family Kids Camp Before?

Yes

If So, Where?

Wishlist for Three (3) Birthday Gifts:

CAMPER'S HEALTH HISTORY

Camper's Allergies

Camper's Illness/Medical Complications

Camper's Disabilities/Limitations

Camper Has An Eating Disorder

Yes

Camper Limitations

Leg or Arm Braces

Hearing Aids

Please indicate date of illness, severity, complications, or any residual impairments of the following:

Respiratory Problems

Heart or Circulation

Pulmonary Edema

Hay Fever

Balance Problems

Insect Bites

Hypoglocyemia

Dizzy Spells

Back Pain

Anaphylactic Shock

Diabetes

Drug Allergy

Musculoskeletal Allergies

Foot Pain

Seizure Disorders

Poison Oak

Fainting

Other

Please explain the results from the Camper’s Emotional and Behavioral History from the previous section.

Are There Any Specific Activities to Be ENCOURAGED for the Camper?

Are There Any Specific Activities to Be DISCOURAGED for the Camper?

CAMPER'S IMMUNIZATION HISTORY

Please fill in dates of basic immunizations and most recent booster as best as you can.

DTP Series

Typhoid

German Measles (Rubella)

Tetanus Booster

Measles Vaccine (live)

DTP Series Booster

Polio OPV (Sabin)

Tuberculin (TB) Test

Small Pox

Mumps Vaccine (live)

PRESCRIPTION MEDICATIONS All medication sent to camp must be in the original container with the pharmacy label on it.

Is the Camper Taking Any Medications?

Yes

Medication 1 Name

Medication 1 Dosage

Medication 1 Times

Medication 2 Name

Medication 2 Dosage

Medication 2 Times

Medication 3 Name

Medication 3 Dosage

Medication 3 Times

What Is (Are) the Medication(s) For?

Camper's Doctor's Name

Camper's Doctor's Phone

Please add any other comments related to HEALTH and MEDICATIONS. 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.

I hereby authorize RFKC’s nurse to administer the above medication(s)

From:

To:

Parent or Legal Guardian Signature

MEDICAL RELEASE FORM

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 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 en route 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 above-listed child to attend the Royal Family Kids’ Camp in the summer of 2024 through OneFamily.

Authorized Signature

Camper's Medicaid Number

PERMISSION TO ADMINISTER OTC MEDICATION

I hereby give the Royal Family Kids’ Camp Registered Nurse permission to administer the following products according to the manufacturer’s instructions or as otherwise specified.

I trust the RFKC 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 the camper may not attend camp.

ACTS IN MOTION - AERIAL ARTS WAIVER

Due to the risk involved in Aerial Arts Training and Performance, a release is required for you as an adult or for your child/teen to participate in this training. Acts In Motion Christian Church & Ministries and staff will maintain the highest precautions for you and your child/teen safety.

I

[adult or parent or guardian]

am in agreement as to the participation of myself, my child/teen

in the Aerial Arts technique and performances at the Acts in Motion church ranch or wherever we have the Aerial Apparatus [and/or] stand put up, or training and performances where we set the Aerial Arts up on a beam in a church or building or circus tent, or on an Aerial Stand. I recognize the attendance and participation may expose myself or my child/teen to risk of injury and harm. I accept this risk and agree that Acts in Motion Christian Church & Ministries and it’s staff will not be held liable should such injury or harm occur during your or their participation.

Due to the DANGEROUS NATURE and the CAUTIONS ABOUT AERIAL ARTS I will NOT OR LET MY CHILD/TEEN on the Aerial Apparatus, or the stand while Alina Parrott is not present. Because of the security training provided in our classes if you or your child/teen are not in the class you or they are NOT permitted to touch the Aerial Apparatus or the stand while Alina Parrott is or is not present. You or your Child/Teen are ONLY AUTHORIZED to be on the Aerial Apparatus, while you or your child/teen is a student, Alina Parrott is present, and ONLY when allowed. I or my child/teen will follow all safety procedures at all times.

I will [and my children will] respect the Aerial Apparatus, and the stand and not tear, rip or destroy it. If something happens I take full responsibility to replace or pay for it with the same value.

Parent or Legal Guardian Signature

Authorized Pick-Up Person

Pick-Up Person's Phone

Any additional information you think our team should be aware of:

Please do not send cameras, money, or any electronic devices with the camper. These items are not needed at camp.

Thanks for registering your camper!