Day Camp Application

Day Camp Session Cost: $200. A NON-REFUNDABLE deposit of $50.00 must accompany the application to ensure the camper's place!

The remaining $150.00 will be due by June 1, 2026. Please return application and check (made payable) to: Tennessee Camp for Diabetic Children 1854 Joseph Terrace

TENNESSEE CAMP FOR DIABETIC CHILDREN

To be filled out COMPLETELY by PARENTS and returned to TCDC.

Full Legal Name of Camper*

Camper's Preferred Name*

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

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email Address*

example@example.com

Birth Date*

Date

Age at Diagnosis*

Name of Insulin(s) Used*

Will Camper Be On Insulin Pump?*

YesNo

If yes, what is the brand?

Carb Ratio*

Continuous Glucose Monitor Name*

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

CeliacLactose IntolerantVeganVegetarian

What size t-shirt does your camper need?

Youth XSYouth SYouth MYouth L

PRIMARY CARE DOCTOR*

Address of Primary Care Doctor*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number for Primary Care Doctor*

Please enter a valid phone number.

DIABETES DOCTOR (if different)

Address of Diabetes Doctor

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number for Diabetes Doctor

Please enter a valid phone number.

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

YesNo

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

I wish to enroll the above-named child as a member of the Tennessee Camp for Diabetic Children for the day camping period. I understand that participating in TCDC activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I also understand that participating in these activities is entirely voluntary and requires participants to abide by all applicable rules and standards of conduct established by TCDC. I have carefully considered the risks involved and give consent for the above-named child to participate in all TCDC camp activities. I release TCDC and all employees, volunteers, related parties, or other organizations associated with TCDC, from any and all claims or liability arising out of this participation.

Signature of Parent or Guardian