2026 TCDC Camper Application

2026 CAMPER'S APPLICATION

This needs to be completely filled out and submitted with a $100 down payment. Your child's spot is not secure without this payment!

Please make checks payable and mail to: Tennessee Camp for Diabetic Children 1854 Joesph Ter Hixson, TN 37343. This fee is non-refundable but counts toward toward the total camp cost. Camp is $750 for one week and $1,025 for two weeks. Payment is due in full by May 15, 2026.

How many weeks of camp is this application for?*

One week (June 14-20)Two weeks(June 14-27)

Camper's Legal Name (Put preferred name in parenthesis, if different)*

Name(s) of Parent(s) or Guardian(s)*

Parent/Guardian Email*

example@example.com

Telephone No.*

Address*

Street Address

Street Address Line 2

CityState

Zip

Pursuant to TN Law, every custodial parent, guardian, or authorized adult must show photo identification and sign the sign out sheet before Camper's release.

If I am not available in an emergency, please contact this person:*

Telephone No.*

Relationship to Camper (aunt, family friend, etc.)*

Camper's Birth Date*

Date

Camper's age at diagnosis*

How old will your child be at the start of camp?*

Will this be your child's first year at TCDC? If so, please tell us how you heard of camp.*

What size camp t-shirt should we order?*

Does your child have any special skills or talents?

Please check the box if your child has any of the following dietary restrictions.

Celiac DiseaseLactose IntolerantVeganVegetarian

We post about camp daily. Do you give permission for your child to appear on our social media accounts, website, or other publication?*

YESNO

Name of child's PRIMARY CARE doctor *

Telephone number for that doctor*

Primary Care Doctor's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of doctor who manages diabetes (if different)

Telephone number for that doctor

Diabetes Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name(s) of Insulin*

Is your child is on an insulin pump?*

YesNo

Is so, what is the brand?

Continuous glucose monitor brand and model*

If your child takes medication for another condition, please give us the medication name, dosage, frequency of administration, and the condition being treated.

Health History Section. Please click the box next the ones that apply to your child.*

If you checked one or more of the boxes above, please give us details.

Please use this space to tell us about any other medical and/or psychological conditions we should be aware of.

Give us the date of your child's last tetanus shot*

Date

Has your child been vaccinated against Covid-19 within the last year? (recommended but not required)*

PLEASE UPLOAD A COPY OF THE FRONT AND BACK OF YOUR HEALTH INSURANCE CARD. FOR ALL EMERGENCY MEDICAL PROCEDURES, YOUR INSURANCE COVERAGE IS PRIMARY AND TCDC'S COVERAGE IS SECONDARY.

Front of card*

Back of card*

This health history is correct so far as I know, and the above-named child has permission to engage in all prescribed camp activities expected as specifically noted on this form. In signing this form below, I understand that, if any information provided on this form is found to be inaccurate in any way, it may limit and/or eliminate the opportunity for such child to participate in any TCDC event or activity. I grant permission for medical examination adjustments in diabetic regiment, treatment or illnesses, and emergency treatment and/or hospitalization if such is deemed necessary by TCDC, including its Camp Director and the camp medical staff. In case of an emergency, I understand that every effort will be made to contact the parent/guardian or individual listed as the emergency contact. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by TCDC to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for such child.

In the case of emergency, TCDC is authorized to disclose protected/confidential health information ("PHICHI") as it deems reasonably necessary to any physician and/or healthcare provider involved in providing medical care to the child. PHI under the Standards for Privacy of Individual Identifiable Health Information, 45 C.F.R. $8160.103, 164.501, et. seq., as amended from time to time, includes examination findings, test results, and treatment provided for purposes of medical evaluation of the child, follow-up and communication with such child's parents or guardian, and/or determination of the child's ability to continue in TCDC activities.

I also authorize the release of any and all hospital records in which treatment is rendered to my child to any insurance company in which the parent/guardian and/or TCDC carries insurance.

Signature of parent or guardian *

Signature of Minor - By signing, I also understand and agree to abide by any restrictions placed on my camp activities*

Do you need us to send information on financial aid?*

YesNo

Please upload a recent (less than six months old) picture of your child's face to accompany this application. *

Tennessee Camp for Diabetic Children is a non-profit organization supported entirely by donations. Anyone able to do so is invited to send a tax deductible contribution. There is a PayPal link on our website.