2025 RFK Camper Application Manhattan, KS

2025 RFK Camper Application

Manhattan, Kansas Camp Dates : Monday June 9 to Friday 13, 2025
Childs Name*

First NameLast Name
Preferred Name/Nickname
Sex*

MaleFemale
Date of Birth*

MonthDayYear
Age*
Emotional Age*
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
School
Grade
Child living with*

Foster ParentsGroup HomeRelativeOther
Name of person living with*

First NameLast Name
E-mail*
Home Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Emergency Contact*

First NameLast Name
Emergency Phone*

Area CodePhone Number
Relationship to Child*
Social Worker

First NameLast Name
E-mail
Agency:
Social Worker Phone

Area CodePhone Number
Night Phone for Social Worker

Area CodePhone Number
Moved in Foster Placement how many times?
Explain any family circumstances that make camp especially important for the child.

Any concerns with sleeping or bedtime routines?
Any activities to be discouraged or restricted?
Any activities to be encouraged?
PRESCRIPTION MEDICATIONS

All medication sent to camp must be in original labeled container with the pharmacy label on it.
Is the child taking any Prescription Medication?*

YesNo
If yes, please indicate medicine and dosage.
Doctors Name*

First NameLast Name
Doctor Phone Number*

Area CodePhone Number
Please add any other comments related to HEALTH and MEDICATIONS

If need more space, Please add any other comments related to HEALTH and MEDICATIONS on an additional sheet. and attatch.0/1000
Child's Medicaid Number#*
MEDICAL RELEASE

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 Royal Family KIDS of Manhattan, KS Camp Nurse to administer the above medication from June 9 thru June 13, 2025.

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 of Manhattan, KS 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 KIDS of Manhattan, KS as legal guardian/social worker/other. I give my permission for the child to attend Royal Family KIDS of Manhattan, KS Camp during camp through Manhattan First Assembly of God.
Printed Name*

First NameLast Name
Autorized Signature*

I certify that I have read, understand, and agree to the provisions of this Activities and Transportation Permission and Release Form, including the separate Medical Release Form included in this application.
Printed Name*

First NameLast Name
Autorized Signature*
Thank you so much for your application to Royal Family KID'S Camp - Manhattan, KS
Should be Empty:

	Often	Sometimes	Not at All
Aggressiveness
Bedwetting
Biting
Eating Disorders
Hyperactive
Lying
Nightmares/Night Terrors
Runs Away
Sexual Acting Out
Steals
Tantrums
Withdrawn

	Yes	No
Gets stressed by loud or sudden noises?
Create a lot of noise?
Avoid or dislikes bright lights, colors, busy pictures?
Crave bright lights, colors, busy pictures?
Crash and bump into people, walls, objects?
Use lots of force when touching, hugging, etc?
Stomp feet when walking, kick feet when sitting?
Like to be under heavy blankets to sleep?
Like to carry heavy things?
Avoid running, hopping, jumping, or rolling?
Dislike heavy backpacks or blankets?
Become very upset when bumped or pushed, even by accident?
Love to spin or swing?
Like to hang upside down?
Like balance beams?
Dislike spinning or doing somersaults?
Get dizzy easily?
Dislike being upside down?
Dislike being picked up or moved?
Dislike when their feet leave the ground?
Unaware of messiness on hands or face?
Like to get dirty?
Like bare feet?
Twirl hand in hair?
Wipe kisses off cheek?
Dislike being dirty or getting hands dirty?
Dislike tags in clothing, seams in socks, etc.?
Sensitive to certain types of fabrics in clothing and/or sheets?

	Yes	No
Acetaminophen (Tylenol) tabs
Acetaminophen Liquid (Tylenol)
Ibuprofen (Advil) tabs
Ibuprofen Liquid (Advil)
Diphenhydramine (Benadryl) tabs
Diphenhydramine Liquid (Benadryl)
Dextromethorphan (Delsym)
Calcium carbonate chewable (TUMS)
Cough Drops (generic)
Phenol spray (Chloraseptic spray)
Decongestant
Antihistamine
Triple antibiotic ointment (neosporin)
Hydrocortisone cream 1%
Hydrogen Peroxide OTC
Solarcaine topical
Immodium
Pepto Bismal liquid and chewables
Calamine or Caladryl Lotion
Lice treatment/shampoo
Bactine (first aid /antiseptic/pain reliever
Sunscreen
Insect Repellent
Bandaids
Ipecac syrup