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.

This must be paid by May 15, 2026!

How do you want to pay for camp after the required $100 down payment? The correct link to a secure payment portal will be emailed to you after submission of this document.*

I would like to pay the remainder of the fee in full online and be doneI would like to make 5 equal payments of $185 online towards the fee (2 wks camper) or 5 equal payments of $130 (1 week camper).I will mail a check

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

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

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

Telephone No.*

TCDC staff shall not release a Camper to anyone who is not an authorized adult. Please list the names and numbers of all adults authorized to pick up camper:*

Please provide a pre-specified password. This can be anything you want; we will ask for it if you need to make changes to any information over the phone relating to authorized adults who can pick up your camper and will also ask for it upon pickup at the end of camp. *

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.

In cases where a camper is the subject of a court order, TCDC must be provided with an original certified copy of the most recent court order and all amendments. In the absence of a court order on file, both parents will be afforded equal access to their child as stipulated by law.

Please sign here indicating you understand the rules surrounding pickup. *

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*

Can your child give his or her own shots yet?*

YesNo

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)*

TCDC PROVISIONS REGARDING COVID-19:

During the TCDC 2026 Camp Session, TCDC will follow the State of Tennessee guidelines for screening, testing, and quarantining of all TCDC personnel and campers. TCDC will cover the costs of any COVID-19 test taken on camp premises. The parent of any camper who begins to exhibit symptoms for COVID-19 will be notified.

I EXPRESSLY ASSUME ALL OF THE RISK ASSOCIATED WITH THE TCDC 2026 CAMP SESSION. I ALSO RELEASE, WAIVE, INDEMNIFY, AND HOLD HARMLESS TCDC FROM ANY LOSS, DAMAGE, INJURY, DEATH, LIABILITY, CLAIM, OR CAUSE OF ACTION ARISING FROM (OR ALLEGED TO ARISE FROM) COVID-19, IN WHOLE OR IN PART.

Your signature here confirms understanding and agreement of the COVID-19 policy. *

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*

The health history I have provided 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.

I agree to the above statement of authorization*

CAMP RULES

1. Visitation. No adults may visit during the camp session because of the adverse impact on camp morale. The only exception is in the case of emergency and then ONLY with the express consent of the Director.

2. Telephone Usage. Campers are not allowed to place or receive telephone calls except with the permission of the Director.

3. Camper Conduct. Campers are responsible for their conduct. All problems should be worked out between the campers and their cabin counselors or with the Camp Director or Assistant Director. Furthermore, TCDC expects each camper to respect other campers and the camp staff. Each camp counselor, as well as any director, may confiscate any item that the Counselor or Director deems to be inappropriate. The Camp Director reserves the right to dismiss any camper who refuses to follow the Camp Rules or who is consistently uncooperative.

4. Leaving Camp. No camper is to leave camp for any reason during the camp session without (a) prior permission from the Camp Director, and (b) the written consent of the camper's custodial parents.

5. Canoe, Paddleboard and Pool Areas. No camper is allowed in a canoe, on a paddleboard, or in the pool without (a) permission of the Canoe Instructor/Waterfront Director, and (b) the presence of a Counselor. While using canoes, each camper must wear a life jacket AND closed-toed shoes. Regarding paddleboards, each camper must wear a life jacket. The Canoe Instructor/Waterfront Director will provide additional regulations.

6. Food and Drink. With the exception of sugar-free candy and ultra-low calorie powdered mixes (e.g., Crystal Light), no food or drink is to be brought from home or sent to camp.

7. Medical and Dietary Matters. All custodial adults must disclose any medical and dietary issues. Additionally, the custodial parent of any camper requiring a deviation from the camp menu must submit the deviation in writing to the camp office at least one month prior to the opening of camp.

8 . Smoking, Alcohol and Illegal Drugs. Campers are not allowed to smoke or vape at camp. The use of drugs or alcohol is strictly forbidden. Disciplinary action will be necessary for those found in possession of or using such substances.

9. Electronics. The following electronics are NOT allowed: (a) computers, (b) tablets, (c) iPads, or (d) any other Wi-Fi capable devices (with the exception of I-phones being used as medical devices). Music players such as iPods, MP3 devices, and CD players are allowed ONLY in the cabins, preferably with headphones.

Bullying Information

Bullying is the repeated aggressive behavior where one person or group of persons is deliberately intimidating, abusing, or coercing an individual with the intention to hurt that person either physically or emotionally or both. There are four types of bullying which can happen separately or simultaneously.

1. Physical bullying such as but not limited to kicking or pushing.
2. Verbal bullying such as name-calling or yelling.
3. Relational bullying such as excluding or rumor spreading.
4. Cyberbullying which involves sending hurtful messages over digital devices.

All instances of bullying will be documented by staff. Any camper who commits an act of physical aggression against another camper or adult will be immediately taken to the Director to determine the severity of the incident. A decision will be made by the Director and administrative staff if the child should be sent home or refused future admission to TCDC or both.

Refunds will not be given for any camper who is sent home from camp for disciplinary reasons.

Parents will be notified under the following circumstances:
1. A camper endangers the lives of others or self.
2. A camper consistently disregards staff instruction or breaks camp rules.
3. A camper is involved in an extraordinarily verbal, written, or physical altercation with another camper.

Camper agrees:

1.) To ask for help from an adult to resolve conflicts.
2.) To show respect for camp equipment/property of others.
3.) To follow all camp rules and use appropriate language at all times.
4.) To follow the anti-bullying policy to create a safe environment.
5.) To arrive and remain at camp with a positive attitude.

Signature of parent or guardian *

Signature of Minor - By signing, I understand and agree to abide by the camp rules, the bullying policy, and to respect any restrictions that may be placed on my camp activities*

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

Do you need us to send information on financial aid? Even if the answer is yes, we still require a down payment of $100.*

YesNo

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.