Clone of Camp Kidney 2025 Camper Registration

WELCOME TO CAMP KIDNEY 2026!!

CAMPER REGISTRATION
We are so excited your child has decided to join us at Camp Kidney 2026. Please complete the entire document in order to secure your child's spot. All campers must ride the bus from PCH to Camp and must stay the entire weekend. Please do not hesitate to reach out with any questions.

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Camp Kidney 2026

Friday, October 23 through Sunday, October 25

Camp Pinerock, Prescott AZ

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Pre-Camp Meeting : SATURDAY, OCTOBER 17 @ 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.

LOCATION: Phoenix Children's Hospital - Cohen Conference Room

1919 E. Thomas Road

Please bring your camper's full list of medications to this meeting along with any medical changes since the application was submitted.

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We look forward to welcoming you to Camp Kidney 2026!
Camper Name:

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

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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
School Grade Next Year (2026/2027)
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:

Other
Select Camp Sweatpants size:

Other
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

Rows	Medication Name	What is the dosage on the bottle (mg)?	How many tablets/pills do you give?	Is this medication given in the AM?	Is this medication given at Lunch?	Is this medication given at Dinner?	Is this medication given in the PM?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Please list any medications not listed above.
Please include any important information regarding your child's medication here:
Medical Questions
IMPORTANT:

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.
Camper's current weight:
Camper's current height:
Allergies

Other
Epi Pen ~ Does your child have an epi pen? If yes, please send with camper.
Please include details or specifics regarding any allergies.
Please provide information regarding symptoms and treatment for known allergies.
Dietary
We will have 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/safe foods. Please use the space below if your camper will have any dietary concerns or issues.
Dialysis
Is your child currently on dialysis?
Hemodialysis
Access:
If hemodialysis cathether, location:
If fistual, location:
Days Maintained of Dialysis:
Fluid Restriction:
Peritoneal Dialysis
Catheter Location:
Does your child urinate?
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:
If yes, Volume (mL) and % Dextrose:
Low Ca+ Dialysate:
Regular Ca+ Dialysate:
Other
Inflow/Outflow Problems:
Medical Supplies
List ALL supplies camper will need at camp- enough for 3 days and 2 nights.

List all extra supplies (extra urinary catheters, g-tube supplies, feeding supplies,cecostomy supplies, glucose monitoring machines, etc.) camper will need at camp.

Supplies List

Rows	Supply	Used For	Special Instructions (How Often?)
1
2
3
4
5

Does your child wear either glasses or contacts?
Does your child wear hearing aids?
IMPORTANT:

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.
Feeds

Please complete the below information if you kid has feeds.

G-Tube Feedings

Rows	Supplies Needed	Formula Name	How much formula do you give?	At what rate?	How many hours?
1.
2.

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.

Rows	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?
If yes, please provide details.

Vaccination Updates & Requirements
Due to the nature of our camper population, many of whom are immunocompromised, we ask that you help us in ensuring that Camp Kidney is a safe space for these campers.

MEASLES:With the increase of Measles outbreaks around the United States, ALL campers and volunteers MUST have received the Measles, Mumps & Rubella (MMR) vaccination to attend camp.

If you child has medical reasons such as immunosuppression and has been advised by medical professionals to not receive MMR vaccine, they will be able to submit documentation from their Nephrologist.

While we understand those who have moral/religious reasons for not vaccinating, we have the obligation to protect all the children at camp, including those with suppressed immune systems.

COVID: Covid-19 vaccination including the recent booster is encouraged for your protection, but not required. Masking is optional, and welcome.

We will be performing temperature checks on all campers and volunteers at Registration prior to boarding the camp bus. Any Camp Kidney participants experiencing cold or flu-like symptoms are encouraged to please refrain from attending Camp.
Please sign that you have read and agree to the above regarding our Camp Kidney vaccination policy.
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
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
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 2025.
Printed Name

First NameLast Name
Signature
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, social media or in any other medium that National Kidney Foundation of Arizona may choose.
Printed Name

First NameLast Name
Signature of Parent/Legal Guardian
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
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 of the application, to your child's Nephrologist/PCH Med Team for completion.

We can't wait to see you in October.

Please do not hesitate to reach out with any questions prior to our Camper Meeting.

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 2026!!

MEDICATION

Medical Questions

Dietary

Dialysis

Hemodialysis

Peritoneal Dialysis

Medical Supplies

Feeds

Treatment Record

Vaccination Updates & Requirements

Conditions of Enrollment for Parents

Emergency Medical Treatment

Medical Release

Media Consent

Alcohol, Tobacco & Drug Policy