Kingdom Family Resources Therapeutic Family Camp Registration Form To inquire about camp scholarships, please send email to ejskfr@gmail.com #1 Child * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Sex Age Grade #2 Child First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Sex Age Grade #3 Child First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Sex Age Grade #1 Parent/Guardian Information * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Cell (###) ### #### #2 Parent/Guardian Information * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Cell (###) ### #### Emergency Contacts #1 * First Name Last Name Relationship to Child Phone (###) ### #### Cell (###) ### #### Emergency Contacts #2 First Name Last Name Relationship to Child Phone (###) ### #### Cell (###) ### #### Additional Information: please answer these questions honestly as this will help us to better serve you during camp. Families will not be turned away due to having traumatic or negative experiences. However, we cannot have family members attend who are actively using substance while attending camp, family members who have active DV issues that could be displayed at camp, or any person who has current charge as a Sex offender in the community. All Information is Confidential. 1) Has your family experienced trauma in their lives or experienced a traumatic event in the last year? * Yes No If yes can you briefly describe 2) Does your family have a history of Domestic Violence? * Yes No If Yes- how has the domestic violence impacted your children? 3) What difficulties are you experiencing as a family that you are hoping we address at camp? * 4) Is there a history of substance use in your family? * Yes No If yes, is the family member in the process of receiving treatment? 5) Is there a history of verbal, physical, or sexual abuse in the family? * Yes No All abuses listed Please identify forms of abuse experienced in your family Allergies (foods, asthma, hay fever, bee stings, medications) Please list all allergies Legal Parent / Guardian Signature * First Name Last Name Date * MM DD YYYY Thank you! We received your registration form, and we will get back to you soon.
