Mentoring Club Child Application

2022-2023 Mentoring Club Application for Campers

Kids who have attended Royal Family KIDS Camp can apply for RFK Mentoring Club. Club will provide fun times with their own matched adult mentor (trained and cleared) for 4 hours a month, plus the once-a-month Club time, during the school year. Approved Mentors can help with transportation and there is no fee for participation. Club participation includes a Club shirt and other Club materials.

You will be contacted by the Club Mentoring Director after this application is received to discuss the match with a qualified mentor for your child during this next school year.

Questions? Email royalfamilykidsclub@gmail.com.

RFK Mentoring Club Child Application (#9)

CHILD PROFILE

First Name

Last Name

Preferred Name (if other than first name - please only use what they are also called at school)

Gender

Male

Female

Address

Address Line 1

Address Line 2

City

State

Zip Code

T-Shirt Size

Child Medium

Child Large

Child XL

Adult Small

Adult Medium

Adult Large

PARENT/CAREGIVER INFORMATION

First Name

Last Name

Email Address

Phone/Mobile (Best number to reach you)

Social Worker Name (if applicable)

Agency

Social Worker Phone Number

RFK MENTORING CLUB MEDICAL RELEASE

Please fill the following out in its entirety.

Child's Full Name

Child's Age

Child's Birth Date (month/day/year)

Family Physician or Clince

Physician Phone Number

Address of Clinic

Street Address

City

State

Zip Code

Check any the child is allergic to:

Penicillin

Sulfa

MSG

Poison Ivy

Poison Oak

Bee Sting

Wasps/Hornets

Nuts

Other

If you checked other, list allergies here:

My child has a history of the following:

Fainting

Headaches

Convulsions

My child is taking the following medications (prescription or otherwise):

My child is receiving medication or has a condition that may affect behavior or increase risks:

Caregiver Name, Relationship to Child

This Medical Release Form is effective on the date of my signature(s) below, and will remain in full force and effect as long as my child participates with Royal Family KIDS Club in any manner; it applies to all Club activities, including both individual meetings with a Club mentor and group meetings, functions, and events (the “Activities”). I hereby give permission for my child to attend and participate in the Activities. I specifically authorize Royal Family KIDS Club to provide for, and arrange in my place, necessary medical care. I authorize the Royal Family KIDS Mentoring Director or any designated adult, in whose care my child has been entrusted, to arrange for and consent to any x-ray examination, anesthetic, and/or medical, surgical and dental procedure and treatment, and hospital care, to be rendered to my child under the general or special supervision, and on the advice of any physician or dentist duly licensed by an appropriate regulatory agency, or the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of such physician, dentist or hospital. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical, dental and/or hospital services rendered to my child pursuant to this authorization. Should it be necessary for my child to be transported home or to medical facilities due to medical reasons or otherwise, the undersigned shall assume all transportation costs. This Medical Release Form will be used only as necessary in the circumstances. Every reasonable effort will be made to first notify a care giver listed below prior to the use of this Medical Release Form.

Sign Here

Date of Signature

Emergency Phone Number

A photocopy of this executed form shall be valid as an original.

RFK CLUBS AND MENTORS TRANSPORTATION/ACTIVITIES PERMISSION AND RELEASE FORM

NO CHILD WILL BE ALLOWED TO PARTICIPATE IN ANY ROYAL FAMILY KIDS CLUB ACTIVITIES UNLESS THIS FORM IS COMPLETED AND SIGNED FOR EACH CHILD.

Child's Full Name

Child's Birth Date (month/day/year)

School

Grade

Caregiver Name, Relationship to Child

2nd Caregiver Name, Relationship to Child

Cell Phone Number for Primary Caregiver

Caregiver Address

Street Address

Address Line 2

City

State

Zip Code

Caregiver Email

Other Emergency Contact Full Name

Relationship of Other Emergency Contact to Child

Other Emergency Contact Phone Number

Other Emergency Contact Email

As the undersigned legal parent or caregiver, I request that my child be allowed to participate in the Royal Family KIDS Clubs Mentoring Program. This Transportation and Activities Permission and Release Form is effective on the date of my signature below, and will remain in full force and effect as long as my child participates with Royal Family KIDS in any manner; it applies to all Club activities, including both individual meetings with a Royal Family KIDS Club Mentor and group meetings, functions, and events (the “Activities”). I hereby give permission for my child to attend and participate in the Activities. I specifically authorize Royal Family KIDS to provide for, and arrange in my place, necessary medical care, as stated in the Medical Release Form on the additional form. I hereby also give my permission for my child to ride in any vehicle designated by the adult(s) in whose care my child has been entrusted while participating in the Activities. In consideration for permitting my child to attend and/or participate in the Activities, I do hereby release, and on behalf of my child release, Royal Family KIDS Club, the local Club’s mentors, Club leaders, volunteer assistants, the host church, and any designated driver of a van, bus, car, or other vehicle used in connection with any of the Activities (“Released Parties”) from any and all claims for injuries, losses, damages, costs and expenses that I, and/or my child, might have against the Released Parties, arising out of, or in any way relating to, my child and the Activities, and I agree to hold the Released Parties harmless from any loss arising from such claims.I certify that I have read, understand, and agree to the provisions of this Activities and Transportation Permission and Release Form, including the separate Medical Release Form.

Sign Here

Date Signed

A photocopy of this executed form shall be valid as an original.

Once this application has been submitted, you will be contacted by the Mentoring Club or Chapter Director regarding your child's participation.

Make sure you scroll to the very end & click "submit".

Thank you!

Address

For the Children Quad Cities Area
PO Box 1654
Moline, IL 61266

Phone

(309) 269-7408

Email Us

wendy@royalfamilyqc.org