The Bahamas Diabetes Association

KIDS WITH DIABETES (KWD) SUMMER CAMP

The Bahamas Diabetes Association (BDA)
APPLICATION FOR REGISTRATION AND CONSENT
Child’s Name
First & Last Name
Gender
Date of birth

MonthDayYear
Parent/Guardian Name (1)

First NameLast Name
Parent/Guardian Name (2)

First NameLast Name
Telephone
Primary ContactFormat: (000) 000-0000.
(Home)
(000) 000-0000
(Mobile Cellular)
(000) 000-0000
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of diabetes
INSULIN:

Humalog   Type a label

Apidra   Type a label

Novorapid/Novolog   Type a label

Other:   Type a label

Dose: Pre-breakfast   Type a label    Pre-Lunch   Type a label   Pre-dinner   Type a label   Snack   Type a label



Sliding Scale or correction factor Used (if applicable):   Type a label

Insulin to carb ratio used (if applicable):   Type a label

Delivery System: Injected/Syringe   Type a label
Injected/Pen   Type a label
Pump (name)   Type a label
Details of pump dose(if applicable)
blank
HYPOGLYCEMIA: Does camper experience any of these symptoms weekly or more often? (Y/N) Yes No

If yes, check all that apply.
Symptoms: Headache Irritability Nausea Shaking Hunger Pale Fatigue Dizziness Twitching Other

Can your child tell when their sugar is low?

blanks
Does the child have any allergies, other chronic illnesses, or medical conditions? If yes, please describe.
Is your child a registered member of KWD? If not, registration is required using the following link: https://form.jotform.com/250713778743869
As the parent/guardian would you be interested in volunteering your time/services during the KWD Summer Camp?
Support Group
Are you interested in being a part of the KWD WhatsApp group?
Please select Youth T-shirt size from the options below:
Please select Adult T-shirt size from the options below:
Informed Consent and Acknowledgment: I hereby give my approval for my child's participation in any and all activities prepared by the Kids With Diabetes (KWD) Summer camp. I assume all risk and hazards incidental to the conduct of activities and release, absolve and hold harmless The Bahamas Diabetes Association (BDA) and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. I will abide by any Code of Conduct, professional standards or other guidance issued by BDA.

Medical Release and Authorization:

As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor's life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission and authorization is hereby granted to proceed only after a reasonable effort has been made to reach me.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Date

DayMonthYear
By acknowledging and signing below, I am delivering an electronic signature that will have the same effect as an original manual paper signature. The electronic signature will be equally binding as an original manual paper signature:
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KIDS WITH DIABETES (KWD) SUMMER CAMP

APPLICATION FOR REGISTRATION AND CONSENT