Camp Kidney 2023 Camper Registration

WELCOME TO CAMP KIDNEY 2024!!

CAMPER REGISTRATION
We are so excited your child has decided to join us at Camp Kidney 2024. Please complete the entire document in order to secure your child's spot. Please do not hesitate to reach out with any questions.

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Camp Kidney 2024

Friday, October 25 through Sunday, October 27

Camp Pinerock, Prescott AZ

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Pre-Camp Meeting : SATURDAY, OCTOBER 19 @ 10AM

Camper and a parent/guardian MUST attend a pre-camp information meeting.

Even if you have attended camp in the past, we ask that you attend this meeting prior to going to camp. At the meeting you will meet your fellow campers, meet our medical team and find out your Color War Team color. We will also answer your questions about camp during this meeting. Please let us know if you are not able to attend in advance and we will schedule a one off meeting with you.

BD HEADQUARTERS

850 W. Rio Salado Parkway, Tempe AZ 85281

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We look forward to welcoming you to Camp Kidney 2024!
Camper Name:*

First NameLast Name
Please include a current photo of your camper. *

Browse Files

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Emergency Contact:*

First NameLast Name
Secondary Emergency Contact:

First NameLast Name
Birth Date:*

MonthDayYear
Campers Age: *
Developmental delays can occur in children with chronic kidney disease (CKD), particularly if their condition has affected their growth or if they've experienced other complications related to their health. Is there is a gap between your child's developmental age and their chronological age? *
If yes, please provide details.
*Please note that NKF AZ/Camp Kidney does not have the resources to provide any type of aid or extra personalized support for your child. Campers must be self-sufficient (able to sleep in bed alone, dress themselves, personal hygiene, etc) to attend Camp Kidney. If you have any questions regarding this policy, please reach out to the NKF AZ team prior to completing the application.*
Gender*

FemaleMaleOther
School Grade Next Year (2024/2025)
Mobile Phone Number:*

Area CodePhone Number
Secondary Mobile Number:

Area CodePhone Number
Email Address:*
Primary Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Secondary Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select Camp Sweatshirt size:*

Y MediumY LargeSmallMediumLargeExtra-large
Medical Diagnosis*
Please let us know if you would like the Medical Team to know anything else regarding your Camper's health
Medical Insurance Company *
Policy Number *
Upload photo of Medical Insurance Card

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Nephrologist: *

First NameLast Name
MEDICATION
ALL MEDICATIONS MUST BE IN THEIR ORIGINAL CONTAINERS. IF
THEY ARE NOT IN THEIR ORIGINAL CONTAINERS, YOUR CHILD
WILL NOT BE ALLOWED TO BOARD THE CAMP BUS.

List ALL medications this camper will need, while away at camp (including OTC and PRN).

Please attach the most current medications sheet/list.

IMPORTANT: Camp Kidney will not have a pharmacy available on site.
If campers do not have the appropriate medications and amounts in hand at the time of departure for camp, THEY WILL NOT BE ALLOWED TO BOARD THE CAMP BUS.

Camp Kidney will ensure that all medications will be given to campers at appropriate times. However, due to the number of campers, times of medications may deviate slightly from their home schedule.

If you do not need all 15 lines, please write in NA in the Medication Name line.

Medication Listing *

	Medication Name	How much do you give with each dose? (ml or # of pills)	What time do you give the medication?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Please list any medications not listed above.
Medical Questions
IMPORTANT:

Please know that YOU as the parent/guardian will be responsible to provide all medical equipment and supplies for this camper before he/she leaves for camp. Be sure to pack enough of everything to last 3 days and 2 nights at camp.

If campers do not have the appropriate supply amounts in hand at the time of departure for camp, THEY WILL NOT BE ALLOWED TO BOARD THE CAMP BUS.
Allergies*

NONEMedicationsFoodsInsect/Bee StingsLiquids/Drinks and FoodOther
Please include details or specifics regarding any allergies.
Please provide information regarding symptoms and treatment for known allergies.
Dietary
Camp Kidney, Camp Pinerock and the Nephrology Dietician team at PCH will work together to create a renal friendly menu for all campers during Camp Kidney. All campers will be offered the same menu. We know that some campers have certain restrictions/requests/save foods. Please contact us if your camper will have any issues with the Camp Kidney renal menu.
Dialysis
Is your child currently on dialysis?*

HemodialysisPeritoneal DialysisN/A
Hemodialysis
Access:
If fistual, location:
Days Maintained of Dialysis:
Fluid Restriction:
Peritoneal Dialysis
PD:

CAPDCCPDOther
Is child anephric?

YesNo
Child's Dry/Target Weight (kg):
Dialysis Unit Name/Phone Number:
Name of Cycler:
Fill Volume (mL):
Last Fill:
Total Volume:
# Cycles:
Total Number of Hours:
Dwell Time:
Dextrose Concentration used:
Mid-Day Exchange:

YesNo
If yes, Volume (mL) and % Dextrose:
Low Ca+ Dialysate:
Regular Ca+ Dialysate:
3L Bags (PD-2)6L Bags ( Low Calcium)Other
Inflow/Outflow Problems:
Medical Supplies
List ALL supplies (e.g.; blood pressure monitor, masks) camper will need at camp- enough for 3 days and 2 nights -> List all extra supplies (extra catheters, g-tube supplies, feeds, Albustix, glucose monitoring machines, etc.) camper will need at camp.

Supplies List

	Supply	Used For	Special Instructions
1
2
3
4
5
6
6
7
8
9
10

IMPORTANT:

Please know that YOU as the parent/guardian will be responsible to provide all medical equipment and supplies for this camper before he/she leaves for camp. Be sure to pack enough of everything to last 3 days and 2 nights at camp.

If campers do not have the appropriate supply amounts in hand at the time of departure for camp, THEY WILL NOT BE ALLOWED TO BOARD THE CAMP BUS.
Treatment Record

Please fill out the below to the best of your abilities. If a category doesn't apply to your camper, please leave blank.

	Date of most recent visit	Reason for visit	Number of visits in past 12 months
Primary Care Doctor
Nephrologist
ER Visit
Visit with Social Working or other Mental Health Professional
Hospitalization
Surgery
Other

If any of the above apply to your camper, please provide any important information:
Any know surgeries/procedures planned before or after Camp?

YesNo
If yes, please provide details.

COVID19 Update
Due to the nature of our camper population,Covid-19 vaccination including the recent booster is encouraged for your protection, but not required. Masking is optional, and welcome.

We will not be testing campers/volunteers before attending Camp Kidney this year. Any Camp Kidney participants experiencing cold or flu-like symptoms are encouraged to please refrain from attending Camp.
Conditions of Enrollment for Parents
1. Camp Kidney accepts no responsibility for the loss, damage, or theft of my child’s property.

2. I understand that my child will be covered solely by the medical insurance policy in which he/she is enrolled.

3. I authorize a licensed professional to dispense any medications recommended or prescribed by a physician to my child.

4. I assume full responsibility for my child’s safety. I agree to release and indemnify Camp Kidney, National Kidney Foundation of Arizona and all of their agents, representatives and employees (paid and volunteer) from any claims, costs, expenses and/or damages which my child may sustain or incur.

5. If my child demonstrates behaviors that are harmful to the camp community, he/she will be sent home. If I am asked to remove my child from camp, it will be at my expense. I acknowledge that I will be held financially responsible for acts of vandalism caused by my child at Camp Kidney.

6. I agree to hold the professional staff of Camp Kidney, National Kidney Foundation of Arizona and all of their agents, representatives, employees and volunteers free from any liability which may arise from any accident or illness which may affect my child during his/her participation at Camp Kidney.

7. If a camper has acute illness while at camp, an authorized parent/guardian will be contacted and required to drive to Camp Kidney/hospital/ED in Prescott, Arizona to pick up the camper. This will be at the expense of family/camper. No exceptions will be made.
All of the above information is correct to the best of my knowledge. My child herein described has my permission to engage in all camp activities, except as noted by myself.
Printed Name

First NameLast Name
Parent/Legal Guardian Signature*

Clear
Today's Date

MonthDayYear
Date
Emergency Medical Treatment
In the unfortunate case of medical and/or surgical emergencies, I authorize National Kidney Foundation of Arizona’s medical volunteers to render or arrange for the person named below to receive any x-rays, anesthetic, medical, dental, surgical procedure, treatment or medical care which is deemed advisable by and is to be rendered under the supervision of any physician, dentist, or surgeon licensed in the state of Arizona.
Printed Name

First NameLast Name
Signature of Parent/Legal Guardian*

Clear
Today's Date

MonthDayYear
Date
Medical Release
I give persmission to Phoenix Childdren’s Hospital to release my campers Medical Records (including Nephrology, Hospitalizations/ER Visits and Medical History) to the National Kidney Foundation of Arizona/Camp Kidney for the sole purpose of Camp Kidney 2024.
Printed Name

First NameLast Name
Signature*

Clear
Today's Date

MonthDayYear
Date
Media Consent
I give permission to Camp Kidney, National Kidney Foundation of Arizona, Camp Pinerock, and other media invited to camp by Camp Kidney/National Kidney Foundation of Arizona to take and release video footage and photography of the person named below during his/her time at Camp Kidney.

I understand that any video or photo may be used on television, in newspapers, magazines, internet, or in any other medium that National Kidney Foundation of Arizona may choose.
Printed Name

First NameLast Name
Signature of Parent/Legal Guardian*

Clear
Today's Date

MonthDayYear
Date
Alcohol, Tobacco & Drug Policy
National Kidney Foundation of Arizona and Camp Pinerock Policy forbid the possession or use of any alcohol, tobacco, and/or un-prescribed drugs any time while at Camp Kidney.

Campers who don’t fully comply with this policy will be sent home immediately. In this instance, an authorized parent/guardian will be contacted and required to drive to Camp Kidney in Prescott, Arizona to pick up the camper. Staff and volunteers who don’t comply will also be sent home. No exceptions will be made.

Your signature below indicates your commitment to abide by this policy in its entirety. Please contact the National Kidney Foundation of Arizona at (602)840-1644 if you have any questions regarding this policy.
Printed Name

First NameLast Name
Signature of Parent/Legal Guardian*

Clear
Today's Date

MonthDayYear
Date
Thank you so much for submitting your Camp Kidney Camper Application.

We will be in touch if there are any issues or missing information from your application.

We will now send Part 2 to your child's Nephrologist/PCH Med Team for completion.

Please do not hesitate to reach out with any questions prior to the Camper Meeting on October 19, 2024.

We can't wait to see you soon!

Ashleigh & Jen

Camp Kidney Camp Directors

*NOTE: If you are unable to upload all required documentations, please email them directly to ashleighs@azkidney.org. Campers will not be considered until application is 100% complete*
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WELCOME TO CAMP KIDNEY 2024!!

MEDICATION

Medical Questions

Dietary

Dialysis

Hemodialysis

Peritoneal Dialysis

Medical Supplies

Treatment Record

COVID19 Update

Conditions of Enrollment for Parents

Emergency Medical Treatment

Medical Release

Media Consent

Alcohol, Tobacco & Drug Policy