2700 Northland Drive Austin, TX 78756
Camp is primarily for children in Foster Care (7 – 11 years of age)
Please note: This form must be filled out in its entirety or your child will lose their place at camp. If you have any questions or concerns please feel free to reach out our placement coordinator, Lori Van Roo, at email@example.com or 916-220-3690.
NOTE: If you will be away from home during camp week, please provide the phone number where you may be reached.
Indicate any known allergies, illness, disabilities, medical/physical limitations or complications.
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 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 Medical 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. I understand that I will be notified in the case of a medical emergency involving my child. However, in the event I or my assignee or the agency the child is with cannot be contacted, I authorize the adult in charge to consent to the providing of necessary medical services if my child is injured or becomes ill. I understand that RFKC will not be responsible for medical expenses incurred solely on the basis of this authorization.
I authorize permission to the assigned personnel of Royal Family Kids’ Camp to give the above medication(s) to the above named minor. I agree to furnish an adequate amount (5 days) of each medication in its own original container. The Royal Family Kid’s Camp personnel will protect my minor and will not administer any medication(s) unless this form is completed. If directions or dosage has been changed since the prescription was filled and picked up you must have written and signed change from the doctor, to give our camp nurse on or before registration day. I hereby give the Royal Family Kid’s Camp (RFKC) nurse(s) my permission to administer over-the-counter medicines and/or products according to manufacturer’s instructions, or as otherwise specified. I trust the RFKC Registered Nurse(s) to use her best judgment as situations arise, and if in doubt, he/she can call for verification.
Examples of products that may be given/used: acetaminophen, ibuprofen, cough syrup, decongestant, throat lozenges, cough drops, Tums, Pepto Bismol, insect repellent, Calamine lotion, Band aids, sunscreen, etc. If child may not be given a product or is allergic to a known product, please specify below.
We ask each family to pay only $20 per child toward the cost of camp. When you submit this form, you will be taken to the donation page of our website.
Thank you for helping us put on the best camp possible for your child!