2019 STAFF APPLICATION

APPLICANT MEDICAL INFORMATION
Applicant's Name *

First Name Last Name
Birth Date *

Month Day Year
Please list any medical conditions *
Please list any allergies *
Please list any medications and any side effects you have from the medications. *
Please list any physical handicaps or conditions preventing you from performing any type of activity *
Please list any special dietary needs as we need to inform our camp chef in advance. *
Please list any other special needs you we may need to be aware of for you at camp. *
EMERGENCY CONTACT
Emergency Contact's Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Alt. Phone Number

Area Code Phone Number
Medical Release and Authorization

In an event I am not able to communicate consent, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of myself in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of my life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for myself. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to obtain consent from myself and then to contact my emergency contacts in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to recieve my consent or to reach them.

Permission is also granted to the Royal Family Kids Camp and Teen Reach Advendture Camp, . and its affiliates including Directors, staff, medical profesionals to provide the needed emergency treatment prior to my admission to the medical facility.

Release authorized on the dates and/or duration of the registered camp(s).

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of myself, in the case where I am unable to give consent and my emergency contacts are absent.
Signature

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State of Illinois Department of Children and Family Services

AUTHORIZATION FOR BACKGROUND CHECK . Child Abuse and Neglect Tracking System (CANTS)
For Programs NOT Licensed by DCFS

NOTE: Do not use this form if you are an applicant for licensure or an employee/volunteer of a licensed child care facility. Please contact your licensing representative
Name *

First Name Last Name
Birth Date *

Month Day Year
Gender *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
List all addresses at which you have resided in the past five years:
List maiden name and/or all other names by which you have been known: (last, first, middle)
I hereby authorize the Illinois Department of Children and Family Services to conduct a search of the Child Abuse and Neglect Tracking system (cants) to determine whether I have been a perpertrator of an indicated incident of child abuse and /or neglect or involved in a pending investigation. I further consent to the release of this information to the agency listed below

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature

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Should be Empty:

Royal Family Kids Camp 2019 Teen Reach Adventure Camp 2019

State of Illinois Department of Children and Family Services