2021 RFK Camper Application Manhattan, KS

2021 RFK Camper Application

Manhattan, Kansas Camp Dates : Monday June 14 to Friday 18, 2021
Childs Name *

First Name Last Name
Preferred Name/Nickname
Sex *

Male Female
Date of Birth *

Month Day Year
Age *
Emotional Age *
Address *

Street Address

Street Address Line 2

City State

Postal / Zip Code
School
Grade
Child living with *

Foster Parents Group Home Relative
Name of person living with *

First Name Last Name
E-mail *
Home Phone *

Area Code Phone Number
Cell Phone

Area Code Phone Number
Emergency Contact *

First Name Last Name
Emergency Phone *

Area Code Phone Number
Relationship to Child *
Social Worker

First Name Last Name
E-mail
Agency:
Social Worker Phone

Area Code Phone Number
Night Phone for Social Worker

Area Code Phone 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? *

Yes No
Doctors Name

First Name Last Name
Doctor Phone Number

Area Code Phone 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 14 thru June 18, 2021.

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 Name Last Name
Autorized Signature *

Mentoring Club Medical Release Form 2021-2022

No child will be allowed to participate in any Royal Family KIDS Mentoring Club activities unless this form is completed and signed for each child.
Childs Name

First Name Last Name
Caregiver's Name:

First Name Last Name
Relationship to Child:
Phone Number

Area Code Phone Number
As the undersigned legal parent or caregiver, I understand that the Medical section in the Camp Application will be shared with the Mentor and Mentoring Director.

This Medical Relase Form is effective on the date of my signature below and will remain in full force and effect as long as my child participates with Royal Family KIDS of Manhattan, KS Mentoring Club in any manner; it applies to any Club activities, events or functions, as well as individual meetings with a Club Mentor (the "Activities").

I hereby give permission for my child to attend and participate in the Activities. I specifically authorize Royal Family KIDS of Manhattan, KS Mentoring Club to provide for, and arrange in my place, necessary medical care.

I authorize the Royal Family KIDS of Manhattan, KS Mentoring Director or any designated adult, in whose care my child has been entrused, to arrange for and consent to any x-ray examination, anesthetic, and/or medical, surgical and dental procedure and treatment, and hospital care, to be rendered to my child under the general or special supervision, and on the advice of any physician or dentist duly licensed by an appropriate regulatory agency, or the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of such physician, dentist or hospital. The undersigned shall be liable and agree to pay all costs and expenses incurred in connection with such medical, dental and/or hospital services rendered to my child pursuant to this authorization. Should it be necessary for my child to be transported home or to medical facilities due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

This Medical Release Form will be used only as necessary. Every reasonable effort will be made to first notify a caregiver listed below, or in this application, prior to the use of this Medical Release Form.
Printed Name

First Name Last Name
Signature

Mentoring Club Transportation/Activities Permission and Release Form 2021-2022

No child will be allowed to participate in any Royal Family KIDS Mentoring Club activities unless this form is completed and signed for each child.
Child's Name:

First Name Last Name
Birthdate:

Month Day Year
School:
Caregivers Name:

First Name Last Name
Relationship to Child:
Other Caregivers Name:

First Name Last Name
Relationship to Child:
Best Contact Phone Number:

Area Code Phone Number
Second Best Contact Phone Number:

Area Code Phone Number
Autocompleted Address
E-mail
Other Emergency Contact:

First Name Last Name
Relationship to Child:
Emergency Contact Phone Number:

Area Code Phone Number
Emergency Contact Email:
As the undersigned legal parent or caregiver or social services agent, I request that my child be allowed to participate in the Royal Family KIDS of Manhattan, KS Mentoring Club Program.

This Transportation and Activities Permission and Release Form is effective on the date of my signature below and will remain in full force and effect as long as my child participates with Royal Family KIDS of Manhattan, KS Mentoring Club in any manner; it applies to any Club activities, events or functions, as well as individual meetings with a Club Mentor (the "Activities").

I hereby give my permission for my child to ride in any vehicle designated by the adult(s) in whose care my child has been entrusted while participating in the Activities.

In consideration for permitting my child to attend and/or participate in the Activities, I do hereby release, and on behalf of my child release, Royal Family KIDS of Manhattan, KS Mentoring Club, the local Mentoring Club's mentors, leaders, volunteer assistants, the host church, and any designated driver of a van, bus, car, or other vehicle used in connection with any of the Activities ("Released Parties") from any and all claims for injuries, losses, damages, costs and expenses that I, and/or my child, might have against the Released Parties, arising out of, or in any way relating to, my child and the Activities, and I agree to hold the Released Parties harmless from any loss arising from such claims.

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 Name Last 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

2021 RFK Camper Application

Mentoring Club Application

Mentoring Club Medical Release Form 2021-2022

Mentoring Club Transportation/Activities Permission and Release Form 2021-2022