Camper Application

CAMPER APPLICATION - SUMMER 2017

Select the camp to attend (age: “as of camp start date”).
RFKC: June 5-9 (ages 7-11)
TRAC Girls: June 22-25 (ages 12-15)
TRAC Boys: June 29-July 2 (ages 12-15)
Bridge: July 6-9 (ages 16-19)

Complete EVERY entry that applies to your child.

CAMPER INFORMATION

First Name*

Last Name*

Preferred Name

Gender*

Birth-date (mm/dd/yyyy)*

Age*

Emotional Age

Reading Level

T-Shirt Size

BOYS: Shoe Size

BOYS: Pants Size

GIRLS: Shoe Size

GIRLS: Dress Size

GIRLS: Bra Size

Name of Camper's Case Worker

Case Worker's Phone #

Case Worker's Email Address

Name of Person Camper is Living With

Relationship to Camper

Street Address

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Email Address

Length of Time Camper has been in this Home
YEARS MONTHS DAYS

Has camper attended any of our camps?
If "Yes", which one? RFKCTRAC GirlsTRAC BoysBridge

Names and ages of other foster children living in this home

Emergency contact during camp

Home Phone

Cell Phone

Work Phone

CAMPER PERSONALITY

Please help us get to know this camper better so we can provide positive interactions and activities at camp. Mark ALL the traits that best describe the camper most of the time.

CAMPER INTERESTS

(Mark ALL their interests)

List the camper’s favorite sports teams.

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MEDICAL HISTORY

Doctor's Name

Facility Name

Doctor Phone Number

Health Insurance/Medicaid

Insurance Number

Approved Medical Facility

Emergency Prescription Source

Emergency Prescription Phone Number

Immunization history: please provide dates of basic immunization and boosters.

*****This information MUST be completed for child to attend camp*****

DTP Series (mm/dd/yyyy)

Booster (mm/dd/yyyy)

Typhoid (mm/dd/yyyy)

Rubella (mm/dd/yyyy)

Tetanus Booster (mm/dd/yyyy)

Measles (live) (mm/dd/yyyy)

Mumps (live) (mm/dd/yyyy)

Polio OPV (sabin) (mm/dd/yyyy)

Tuberculin (TB) (mm/dd/yyyy)

Small Pox (mm/dd/yyyy)

Does the camper have seasonal allergies?

Does the camper have food/drug allergies?

If "yes" to ANY allergies, please describe.

Is the camper allergic to bees?

Does the camper carry an epi pen?

Please list ANY of camper's known medical conditions (mental or physical), illnesses or surgeries treated by your doctor.

Does the camper have any physical disabilities or other limitations?

If "yes", please describe.

Is the camper diabetic?

Does the camper have asthma?

Is the camper pregnant? *If "yes", the camper must have a medical release signed by her doctor.

MEDICAL HISTORY (continued)

Please list ALL medications the camper is currently taking (including OTC drugs).

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NOTE: Medications must be in original prescription bottles from prescribing physician.

Any additional information about the child's medication can be added below:

EMOTIONAL AND BEHAVIORAL HISTORY

Indicate the degree to which the camper displays the following emotions/behaviors. Please answer honestly.
Negative behaviors do not disqualify a camper from attending camp.

Aggression/Anger

Bedwetting

Biting

Eating disorder

Hyperactive

Learning difficulties

Lying

Nightmares

Night terrors

Runs Away

Tantrums

Acting out sexually

Stealing

Withdrawn

Please explain ANY behaviors that occur FREQUENTLY and describe how they are handled.

Is there anything else we should know about the camper in order to better meet their needs while at camp?

PERMISSION TO ADMINISTER FIRST AID AND OTC MEDICATION

I hereby give the nurse from any listed camp permission to administer first aid and the following over-the-counter medication according to manufacturer’s instructions, or as otherwise specified.

I trust the nurse from any listed camp to use his/her best judgment as situations arise, and if in doubt, the nurse can call for verification.

By checking the following box and typing your full name, you agree to the above statement. Please also date the agreement.

I accept the terms stated above.

Electronic Signature (Guardian)


Date (mm/dd/yyyy):

Electronic Signature (Camper, Age 18-19)


Date (mm/dd/yyyy):

Check YES or NO if child is allowed to have any of the following over the counter medications listed:

List any special instructions (if required):

Sunscreen

Insect Repellant

Lip Balm

Rash Ointment

Tylenol

Ibuprofen

Antiseptic Ointment

Band-Aid

Anti-itch Cream

Alcohol Wipes

Cough Syrup

Cough Drops

Decongestant

Antihistamine

Pepto-Bismol

Tums

Other

LEGAL GUARDIAN

As legal guardian of camper,, I agree that all information provided to Love Fosters Hope is correct and that I approve their participation in any of the camps listed above.

Name (First and Last)

Date (mm/dd/yyyy)

Electronic Signature

CAMPER, AGE 18-19 (as camp start date)

I agree that all information provided to Love Fosters Hope is correct and that I approve my participation in any of the camps listed above.

Name (First and Last)

Date (mm/dd/yyyy)

Electronic Signature

Please contact us if you have any additional questions.

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