DO NOT PRINT THIS APPLICATION...It Must be filled out and submitted online. If you have problems completing the form, please contact us directly. The application may take 20-30 minutes to complete and you will need to attach a jpg photo to complete it. Applications are processed on a first come, first served basis. YOU WILL HEAR BACK FROM US VIA EMAIL within the week. There is no fee to attend camp. All Campers must be between the ages of 7-11 at the time of camp: July 20-24, 2020. We work hard all year to make this camp happen and we want a full camp. Please be courteous and contact us if circumstances change and your child is unable to attend.
Questions?
IF YOU HAVE QUESTIONS about available space, if your child qualifies for camp, or have other questions or concerns about RFKC: Please contact the RFKC Child Placement Coordinator Sharon Hinson at Mrssharonhinson@yahoo.com or feel free to call the director, Chuck Peterson at 843-568-3352
Name of Person Filling Out This Application
*
First Name
Last Name
Relationship To Child
*
Caseworker
Caregiver
Child's Information
Child's Name
*
First Name
Last Name
Preferred Name (if child has one)
If child is a returning camper and had a DIFFERENT NAME LAST year, please let us know!
First Name
Last Name
Gender
*
Male
Female
Birth date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Age at Time of Camp (July 20, 2020)
*
7 years old
8 years old
9 years old
10 years old
11 years old
Emotional Age
*
Very mature
About normal
Immature
This child will be entering this grade in the fall of 2020.
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
Child's T-Shirt Size
*
Child Medium
Child Large
Adult Medium
Adult Large
Adult Extra Large
Child's Shoe Size (Round up for half sizes)
*
1
2
3
4
5
6
7
Is this child a returning RFKC Camper?
*
Yes, returning RFKC Camper
No, not a returning RFKC Camper
Don't know if child has been to RFKC before
If you know the name of the camper's counselor, please let us know.
Siblings of Child Applying to RFKC This Summer
If siblings of this child will ALSO be applying to come to camp, please provide their name so we can try and get all siblings to camp this summer. Please complete a separate application for each child. Multiple children listed on one application may be missed.
If a sibling of this child is applying to camp, please tell us who that is.
First Name
Last Name
This sibling is a...
Biological Sibling
Foster Sibling
Sibling in Adoptive Family
If 2nd sibling is applying to camp, please tell us who that is.
First Name
Last Name
2nd sibling is a...
Biological Sibling
Foster Sibling
Sibling in Adoptive Family
If 3rd sibling is applying to camp, please tell us who that is.
First Name
Last Name
3rd sibling is a...
Biological Sibling
Foster Sibling
Sibling in Adoptive Family
If 4th sibling is applying to camp, please tell us who that is.
First Name
Last Name
4th sibling is a...
Biological Sibling
Foster Sibling
Sibling in Adoptive Family
Parent/Guardian Information
This home is best described as...
*
Foster Home
Adoptive Parents
Group Home
Kinship
Biological Parent(s)
At time of camp, how long will this child have been living in current home?
*
less than 4 months
4-6 months
6-11 months
1-2 years
2-3 years
3-4 years
4+ years
Total # of foster or residential placement for the child (including current home).
Home Mailing Address (for camp correspondence)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Parent or Legal Guardian #1
*
First Name
Last Name
Relationship to Child
*
Best Phone Number
*
-
Area Code
Phone Number
This phone is a:
Cell Phone
Work Phone
Home Phone (land line)
Parent/Guardian #1 Email Address
Parent or Legal Guardian #2
First Name
Last Name
Relationship to Child
Parent or Legal Guardian #2 Best Phone Number
-
Area Code
Phone Number
This phone is a:
Cell Phone
Work Phone
Home Phone (land line)
Parent/Guardian #2 Email Address
Authorized to Pick Child Up From Camp on Friday, July 24th
Who (other than caseworker or caregiver ) is an authorized adult that may pick this child up after camp July 24? **Government ID required**
*
First Name
Last Name
Cell Number for Authorized Adult
*
-
Area Code
Phone Number
SECOND authorized adult. **Government ID required**
First Name
Last Name
Cell Number For Authorized Adult
-
Area Code
Phone Number
Caseworker/Child Placement Agency Information
Caseworker Name
*
First Name
Last Name
Caseworker Email
*
Caseworker Agency
*
Example: Charleston Co. Berkeley Co., Bair, Mentor, Eagle Harbor, Lifeline Child
Caseworker Phone 1
*
-
Area Code
Phone Number
Caseworker Phone 2
-
Area Code
Phone Number
Caseworker's Supervisor
*
First Name
Last Name
Supervisor Email
Supervisor Phone Number (not intake #)
*
-
Area Code
Phone Number
Guardian Ad Litem
*
First Name
Last Name
GAL Email
example@example.com
GAL Phone Number
*
-
Area Code
Phone 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 bed
Rarely wets the bed
Frequently wets the bed
Do 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 aggressive
Rarely aggressive
Frequently aggressive
Always Aggressive
Do not know if child is aggressive
Please explain aggressive behavior. (What may trigger aggressive behavior or to whom child is aggressive.)
What strategies or techniques have you successfully used to deal with aggressive behavior?
Does the child deal with any of the following eating disorders or issues around food?
*
Anorexia
Bulimia
Overeating/Gorging
No Eating Disorders
Hording or Stealing Food
Do Not Know Of Any Eating Disorders
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 calm
Somewhat hyperactive
Frequently hyperactive
Always hyperactive
Don't know about hyperactivity
Please let us know if any of the following learning difficulties exist for this child.
Hearing impairment
Vision impairment (that would affect time at camp)
Reading difficulties
Don't know about learning difficulties
How often does this child lie?
*
Never lies
Rarely lies
Frequently lies
Can't tell lies from truth
Don't know if this child has a habit of lying
Please let us know how often this child has nightmares.
*
Never or rarely has nightmares
Frequently has nightmares
Don't yet know about nightmares
Please let us know how often this child has night terrors.
*
Never or rarely has night terrors
Frequently has night terrors
Don't yet know about night terrors
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 or rarely runs away
Frequently runs away
Don't yet know if child runs away
Please let us know if - or how - this child may act out sexually.
*
Does not act out sexually
Do not know if sexually acts out
Touches self
Touches other children
Flirts or pays inappropriate attention to adults
If this child does act out sexually, please explain.
How often does this child steal?
*
Never or rarely steals
Frequently steals
Do not know about stealing yet
Know of stealing in the past, but not currently
How often does this child have tantrums or anger issues?
*
Never or rarely has tantrums or anger issues
Frequently has tantrums or anger issues
Don't know about tantrums or anger yet.
If this child does have tantrums or anger issues that are beyond normal childhood frustrations, please describe successful strategies or techniques you have used.
How often does this child withdraw?
*
Never withdrawn
Rarely withdrawn
Frequently withdrawn
Don'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!) This information will help our counselors and staff connect more quickly. Simple things can make a big difference.
*
Medical History + Prescription Medication Information
REQUIRED: ATTACH A COPY OF CHILD'S IMMUNIZATION RECORD
List all known allergies to food, plants, medications, animals, etc.
*
This child's swimming ability is...
*
Poor Swimming Ability
Good or excellent swimming Ability
Do Not Know Swimming Ability
Illnesses and Medical Complications Past or Present (check all that apply)
*
Respiratory Problems
Seasonal Allergies
Food Allergies
Medicine Allergies
Topical Allergies (lotion, sunscreen, etc.)
Dizzy Spells and/or Fainting
Back Problems
Seizure Disorders
Anaphylactic Shock
Balance Problems
Asthma
ADD or ADHD
Hypoglycemia
Heart or Circulation Problems
Pulmonary Edema
Type 1 Diabetes
Type 2 Diabetes
Insect Bite Allergies (i.e. mosquitoes, bees, ect.)
Recent Surgery
Recent Broken Bones
NONE
Please explain each medical issue you checked above. (If you did not check anything, please say DOES NOT APPLY."
*
What 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.
*
All of the Below
Sunblock/Sunscreen
Insect Repellent
Lip Balm
Rash Ointment
Tylenol
Advil
Antiseptic Ointment
Bandaids
Anti-Itch Cream
Hydrogen Peroxide
Rubbing Alcohol
Cough Syrup
Cough Drops
Decongestant
Antihistamine
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 ensure that all instructions are clear and that the necessary dosage is adequately supplied for the duration of camp (Monday, July 29, to Friday, July 24, 2020.) I authorize RFKC medical staff to administer the medications.
*
Yes, I understand that sharing medical info, medications, and dosages are my responsibility. I will bring medications in their original containers.
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.)
Additional information we need to know about the above prescription drugs, vitamins, or over-the-counter medications sent to camp - or - additional meds if any.
*
Prescribing Doctor
*
First Name
Last Name
Doctor's Phone Number
*
-
Area Code
Phone 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
Cancel
of
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 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 minor named in this application to attend Royal Family KIDS Camp in the summer of 2019 through Summerville Calvary Chapel.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
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PERMISSION TO TRANSPORT
The above mentioned organizations are hereby authorized to transport said minor by charter bus from the registration location in Summerville, SC on Monday, July 20th and transport the minor from the campground to the pick-up location on Friday, July 24th. They are also authorized to transport to a hospital in the event of a non-serious injury. I understand that if I should, for any reason, desire to retrieve said minor from camp before Friday, July 24th, 2020, I will first be required to make arrangements with the directors and meet at an agreed upon location. I, by my signature, release Summerville Calvary Chapel, Royal Family Kids inc, and any other involved parties from liability in relation to travel to and from camp.
Name
*
First Name
Last Name
Signature
Clear
Date
*
-
Month
-
Day
Year
Date Picker Icon
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*
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