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Supervised Visitation

Camp

Make A Referral

Supervised Visitation

Camp

Make A Referral

Folder: Services

Supervised Visitation

Camp

Make A Referral

Future Legacy Camp

Camper Registration:

Child's Name *

First Name

Last Name

Preferred Name

First Name

Last Name

Sex: *

Male

Female

Birthday: *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

School *

Last grade completed? *

Reading Level *

The child is living with *

Foster Parent

Group Home

Relative

Other

Name of the person the child is living with *

First Name

Last Name

Email of the person the child is living with *

Primary phone of the person the child is living with: *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone: *

(###)

###

####

Relationship to Child *

Social Worker

First Name

Last Name

Social Worker's Email

Social Worker's Daytime Phone

(###)

###

####

How many times has the child moved in foster placement

Reason child was moved placements

Explain any unusual family circumstances that make camp especially important for the child: (for example: recent crisis, being moved in foster placement, severe economic needs, etc.)

1. Does the child exhibit aggressiveness? *

Often

Sometimes

Not at all

Please describe the behaviors for which "often" or "sometimes" was checked.

-Last occurrence -Who is it usually directed towards -Frequency -Situation around last occurrence

2. Does the child exhibit bed wetting? *

Often

Sometimes

Not at all

Please describe the behaviors for which "often" or "sometimes" was checked.

-Last occurrence -Frequency -Situation around last occurrence

3. Does the child exhibit biting? *

Often

Sometimes

Not at all

Please describe the behaviors for which "often" or "sometimes" was checked.

-Last occurrence -Who is it usually directed towards -Frequency -Situation around last occurrence

4. Does the child exhibit eating disorders? *

Often

Sometimes

Not at all

Please describe the behaviors for which "often" or "sometimes" was checked.

What does eating disorder mean to you? -Binging -Purging -Refusing to eat -Last occurrence -Frequency -Situation around last occurrence

5. Does the child exhibit hyperactive behavior? *

Often

Sometimes

Not at all

Please describe the behaviors for which "often" or "sometimes" was checked.

6. Does the child exhibit any l earning disabilities? *

Often

Sometimes

Not at all

Please describe the behaviors for which "often" or "sometimes" was checked.

-What does leaning disabilities look like for this child

7. Does the child have lying tendencies? *

Often

Sometimes

Not at all

Please describe the behaviors for which "often" or "sometimes" was checked.

-Frequency -Situation around last occurrence

8. Does the child exhibit night terrors? *

Often

Sometimes

Not at all

Please describe the behaviors for which "often" or "sometimes" was checked.

-Frequency -Last occurrence -What helps after awakend -What does this look like for the child

9. Does the child exhibit nightmares? *

Often

Sometimes

Not at all

Please describe the behaviors for which "often" or "sometimes" was checked.

-Frequency -Last occurrence -What helps after awakend -What does this look like for the child

10. Does the child run away? *

Often

Sometimes

Not at all

Please describe the behaviors for which "often" or "sometimes" was checked.

-Last occurrence -Frequency -Situation around last occurrence

11. Does the child act out sexually? *

Often

Sometimes

Not at all

Please describe the behaviors for which "often" or "sometimes" was checked.

-Last occurrence -Exhibited towards a certain gender or person -Frequency -Situation around last occurrence

12. Does the child exhibit stealing? *

Often

Sometimes

Not at all

Please describe the behaviors for which "often" or "sometimes" was checked.

-Last occurrence -Who is it usually directed towards -Frequency -Situation around last occurrence

13. Does the child exhibit tantrums? *

Often

Sometimes

Not at all

Please describe the behaviors for which "often" or "sometimes" was checked.

-What helps the child calm down after event

14. Does the child withdraw? *

Often

Sometimes

Not at all

Please describe the behaviors for which "often" or "sometimes" was checked.

-What helps the child re-engage

Describe any coping skills the child uses: *

Child's current emotional age *

Describe any triggers the child may have: *

Child's sibling order: (If an only child, enter 0) *

The child's swimming ability is *

Good

Poor

Don't know

Camper T-Shirt Size: *

Child Medium

Child Large

Adult Small

Adult Medium

Adult Large

Adult Extra Large

Has the child attended a Royal Family Kids Camp before? *

Yes

No

Reference 3 Email: *

Reference 3 Phone: *

(###)

###

####

Where or what Royal Family Kids Camp has the child attended? *

Child's favorite color *

Child's Favorite Sport *

Child's favorite animal *

Child's favorite movie *

Any other details you think we need to know about the child:

Indicate known allergies: *

Indicate known illnesses: *

Indicate known disabilities: *

Indicate known physical limitations: *

Indicate known medical complications: *

Indicate known medical complications: *

Does the camper have any of the following?

Leg or Arm Braces

Hearing Aids

Eating Disorders

Please indicate the date of illness, severity, complications, and any residual impairments for the questions below:

Respiratory Problems

Heart or Circulation

Pulmonary Edema

Hay Fever

Balance Problems

Insect Bites

Hypoglycemia

Dizzy Spells

Back

Anaphylactic Shock

Diabetes

Diabetes

Drug Allergy

Musculoskeletal Allergies

Foot

Seizure Disorders

Poison Oak

Fainting

Other

Please list any details from the questions above:

Any specific activities to be encouraged?

Any specific activities to be restricted?

Please fill in the dates of basic immunications and most recent booster as best as you can:

DTP Series

DTP Booster

Typhoid

German Measles (Rubella)

Tetanus Booster

Measles Vaccine (Live)

Mumps Vaccine (Live)

Polio OPV (Sabin)

Tuberculin (TB) Test

Small Pox

All medications sent to camp must be in original container with the pharmacy label on it.

Is your child taking any medications? *

Yes

No

Please indicate the name, dosage, and times to be taken: *

What are the medications for? *

Child's Doctor's Name *

First Name

Last Name

Child's Doctor's Phone *

(###)

###

####

Please add any other comments related to HEALTH and MEDICATIONS:

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 Future Legacy Camp nurse to administer the above medications from:

Start Date

MM

DD

YYYY

End Date

MM

DD

YYYY

Parent or Legal Guardian: *

First Name

Last Name

MEDICAL RELEASE FORM

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 Future Legacy 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 Future Legacy as legal guardian/social worker/other. I give my permission for (childsName) to attend Future Legacy Camp in the summer of 2025 through Life360 Church.

Parent or Legal Guardian: *

First Name

Last Name

Relationship to child:

Child's medicaid #:

OVER-THE-COUNTER MEDICATIONS *

I hereby give the Royal Family KIDS' Camp Registered Nurse permission to administer the following products according to manufacturer's instructions, or as otherwise specified. I trust the RFK Camp Registered Nurse to use her best judgment as situations arise, and if in doubt, he/she can call for verification. Please SELECT APPROVED MEDICATIONS listed below, or LEAVE MEDICATION BLANK IF NOT-APPROVED. This form must be completely filled out by the primary caregiver who signs below, or the camper may not attend camp.

Sunblock

Insect Repelent

Lip Balm

Rash Ointment

Tylenol

Antiseptic Ointment

Bandaids

Anti-Itch Cream

Hydrogen Peroxide

Cough Syrup

Cough Drops

Decongestant

Antihistamine

Ipecac Syrup

Please specify anything desired that is not listed above:

Parent or Legal Guardian: *

First Name

Last Name

Phone Number

(###)

###

####

Person authorized to pick up child: *

First Name

Last Name

Thank you!

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