• Camp New Day | Camper Application

    DO NOT WAIT FOR FUNDING!! SUBMIT APPLICATION IMMEDIATELY
  • Please mark one:*
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Diagnosis
     - -
  • Sex

  • Choose Camper's t-shirt size

  • Child Sizes
  • Adult Sizes

  • CONSENT:

    I authorize medical treatment for my child by the physicians and health professional staff of the Rotary Diabetic Camp. I consent and agree that the physicians and health professional staff of the diabetic camp or any medical staff to whom my child is referred may administer such medical treatment as is determined necessary in case of illness or injury to my child. I consent to the performance of those operations and/or medical treatment and procedures in addition to, or different from, those now contemplated that may arise from unforeseen conditions that the physicians and health professional staff of the camp may consider necessary or advisable for my child's health and safety.

    Because of the variability of the activities during the diabetic camp session, I understand that it may be necessary for the Medical Staff to adjust or alter my child's diet or insulin schedule. In the event of an illness or injury for which my child is hospitalized, I will be notified. I further consent to the release of my child's medical records to any healthcare professional to which my child is referred for medical care.

  • Date
     - -

  • Medical Information Form (to be completed by parents)

    If the child is on shots, fill out the following
  • Sex
  • Last HgbA1C Level Date
     / /
  • My child takes shots with an (please mark one)
  • My child uses the following long acting basal insulin (please mark one)

  • What is your child's dose of long-acting insulin and when is it given?
    units at (what time)
    units at (what time)

  • Does your child use NPH insulin?

  • If yes, what doses and when?
    units at (what time)    
    units at (what time)

  • Which of the following insulins does your child use for food coverage and correctional dosing?
  • Rows
  • Rows

  • Medical Information Form (to be completed by parents)

    If the child is on a Pump Fill, fill out the following
  • Last HgbA1C Level Date
     / /
  • My child is on the following type of pump
  • Does your child's pump work with a GM?
  • Is your child's pump one that is automatically adjusted with CGM?
  • If you are on the Omni pod 5:
  • Which of the following insulins does your child use in their pump?

  • My child's Pump's settings are

  • Rows
  • Rows
  • Rows

  • Diet Information

  • Mark the method your child usesto identify carb amounts they eat
  • Rows
  • Does your child have any food allergies or intolerances?

  • General Information

  • Does your child have any other chronic medical conditions or illness?
  • Is your child allergic or intolerant to any medications?

  • Medical Reoprt

    To be completed by Physician
  • Date of Birth
     - -
  • Sex
  • Date of examination
     / /
  • Format: (000) 000-0000.
  • Should be Empty: