Summerville RFKC Camper Application 2020

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 *

Month Day 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	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
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
Enter the message as it's shown *
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Questions?

Child's Information

Siblings of Child Applying to RFKC This Summer

Parent/Guardian Information

Authorized to Pick Child Up From Camp on Friday, July 24th

Caseworker/Child Placement Agency Information

Background/Behavior Information

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!

Medical History + Prescription Medication Information

Prescription & Over-the-Counter Medications

Permission

PERMISSION TO TRANSPORT