REGISTRATION FORM - DAY CAMP     FOR THE CHILDREN    2022
Sign in to Google to save your progress. Learn more
Child's Last Name, First Name *
Child's Preferred Name *
Child's Sex, Birthdate, Age *
What grade is this child going into? *
Child's Complete Address *
The child is living with: *
Name(s) of the person the child is living with: *
Home phone and work phone of the person the child is living with (please include the area code): *
Child's Emergency Contact: *
Emergency Contact Phone (please include the area code):
Relationship of the emergency contact to the child *
Social Worker Name and Phone Number: *
Child's Emotional/Behavioral History: *
Often
Sometimes
Not at All
Agressiveness
Eating Disorders
Hyperactivity
Learning & DIsabilities
Runs Away
Sexual Acting Out
Tantrums
Withdrawn
Provide helpful details regarding the above: *
                                                         CAMPER DETAILS
The camper's swimming ability is: *
Has the child attended a Royal Family KIDS Camp/ Event before? *
If yes, the where? *
Camper T-Shirt Size: *
                                                          HEALTH HISTORY
Indicate all known allergies, illnesses, disabilities, physical limitations, or medical complications.
Allergies *
Illnesses/medical complications *
Disabilities/Limitations *
Does the child have these? *
Yes
No
Leg brace
Arm brace
Hearing aids
Eating disorder
Indicate illness, severity, complications, and any residual impairments: *
Required
Dates and details for above items *
                                             PRESCRIPTION MEDICATIONS
The FTC Day Camp will be from the hours of 8:00 am to 8:00 pm.  If your child will need any medications between those hours, please list below.  All medications must be in the original container with the pharmacy label on it.
Prescription medications needed during camp: *
Is your child taking any medications? *
If yes, then provide the name of the medication, dosage, and times to take it: *
For prescriptions listed please provide the doctor's name phone number, and what the prescription is for: *
Please add any other comments related to Health and Medications below: *
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 FTC to administer the above medication during the operation of the camp.  My printed name below signifies my acknowledgement of the above statement and is considered equivalent to my signature upon application submission. *
                                         OVER-THE-COUNTER MEDICATIONS
I hereby give the For the Children permission to administer the following products according to manufacturer’s instructions, or as otherwise specified.  I trust that For the Children to use her best judgment as situations arise, and if in doubt, he/she can call for verification.


Please check YES or NO for the medications listed below.  This form must be completely filled out by the primary caregiver who signs below, or camper may not attend camp *
Yes
No
Sunblock
Insect Repellant
Lip Balm
Rash Ointment
Tylenol
Antiseptic Ointment
Band Aids
Anti-itch Cream
Hydrogen Peroxide
Cough Drops
Antihistamine
Other
                                                     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 For the Children 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 For the Children as legal guardian/social worker/other.  I give my permission for my child listed below to attend a for the Children Camp / Event in the summer of 2022 through Erie First Assembly.
Child's Name: *
Child's Medicaid # *
Signature - My printed name below signifies my acknowledgement of the Medical Release above and is considered equivalent to my signature upon application submission. *
Relationship to child *
Date *
MM
/
DD
/
YYYY
Parent or Legal Guardian Signature - My printed name below signifies my acknowledgement of the Medical Release above and is considered equivalent to my signature upon application submission. *
Person authorized to pick-up child: *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms