Kids for a Cure Camp 2025

Kids for a Cure Camp
June 16–20
9:00 a.m.–2:30 p.m.

Presbyterian Church of Fredericksburg
810 Princess Anne Street
Fredericksburg, VA 22401

The week includes:

ARTS ★ CRAFTS ★ ACTIVITIES ★ GAMES ★ NUTRITIONAL COACHING

Kids for a Cure Club summer day camp for children with type 1 diabetes was established in 2006. It is staffed with health professionals, counselors, and junior counselors trained in diabetes care.

The camp is a great opportunity for children with type 1 diabetes to have fun with other children who share their daily challenges.

Camp Fee & Application Policy:

The cost for camp is $175 for campers and $75 for Junior Counselors. Payment must be received in order to reserve your spot. This includes snack, lunch, a t-shirt, camp picture, and the day’s activities. Financial aid is available for those who qualify.

Camp requires a minimum of 10 campers and is limited to a maximum of 20 campers (children who have completed 1st grade – 12 years old). Once 20 campers have been accepted, we will hold further applications on a waiting list.

Confirmation of camp acceptance will be sent via e-mail.

Counselor application (ages 15 and older)

Junior counselor application (age 13 or 14)
1. Requirements: must have completed 1st grade to 12 years of age.
2. Complete and sign the following forms and return them with payment by May 22, 2025.
  - Camp Guidelines
  - Camp Rules
  - Diabetes Information
  - Health and Emergency Authorization
  - Health History Information
  - Medication Administration Form
  - Pick-Up Information
  - Release of Liability and Assumption of Risk
  - Pool Day
  - Consent to Photograph/Interview and Release of Liability
3. Mail camp fee of $175.00* with a check payable to Kids for a Cure Club to:
  Kids for a Cure Club
  c/o MWH Diabetes Management, Katie McGuigan
  4710 Spotsylvania Parkway, Ste. 200
  Fredericksburg, VA 22407
  
  NOTE: Camp is limited to a maximum of 20 campers and will be processed in the order the paperwork and payment is received. Once 20 applications are accepted, we will start a waitlist.
  
  *Financial aid is available for those that qualify.
4. Physician orders and approval form due May 29, 2025. Campers will not be allowed to attend camp without this being completed.
  
  Physician’s Approval and Orders – Injections OR
  Physician’s Approval and Orders- Pump
IMPORTANT DATES:

Camp Orientation & Parent Meeting: Thursday, May 29, Time TBD

Camp: Monday June 16–Friday June 20, 2025, 9:00 a.m.–2:30 p.m.

Closing Ceremony for family and friends & wrap up: Friday June 20, 1:30 p.m.–2:30 p.m.

Questions: Call 540.741.2210 or email Stefanie Rekdal, Team Lead Stefanie.rekdal@mwhc.com
Camp Guidelines
Camper Name*

First NameLast Name
T-shirt size*
1. Campers may supply their own snacks and/or drinks if the child is allergic to or dislikes chosen menu. Menu will be provided prior to week of camp. Lunch and snacks will be provided each day. If you have any questions, please call our office.
2. Participants must always wear socks and tennis shoes. No hard-sole shoes or sandals are allowed. Participants should wear clothes that could get dirty. No jewelry is allowed for safety reasons.
3. A daily backpack is suggested to hold the child’s supplies. Every effort will be made to safeguard the child’s belongings, but the camp cannot be held responsible for lost or stolen items. Label all items when possible, using a permanent marker.
4. If your child self-medicates, he/she will be allowed to do so with adult supervision.
5. Please send morning blood glucose reading IN WRITING to camp each day.
I attest that I have read and understand the above guidelines:
Parent/Guardian Signature (Guidelines)*

Clear
Date*

MonthDayYear
Date
Camp Rules
- Have respect for leaders when they are speaking, for facilities and equipment, and for fellow campers.
- Food must be eaten in designated areas. All trash must be disposed of properly.
- Return all equipment and/or supplies when finished using it/them.
- Participants are responsible for their actions at all times. The family may be billed for any damages caused to any facilities.
- Report any damaged or broken property or equipment to camp staff.
- No rough horseplay will be tolerated during camp.
- Cell phone use will be allowed for medical purposes only.
- Those who do not follow the above rules will either lose privileges or be asked to take time out from activities.
- Parents need to escort their child into the camp facility and check in with a staff member before leaving.
- Parents are asked to be prompt when picking up their child each afternoon at 2:30 pm, and to check out with staff before leaving.
NOTE TO PARENT OR GUARDIAN:

If you have any concerns or questions regarding camp rules or policies, please do not hesitate to contact Stefanie Rekdal, MWHC Team Lead at 540.741.2210 or stefanie.rekdal@mwhc.com. We will discuss any concerns with the camp staff and planning committee.

I/We have read the above rules and guidelines and discussed them with my/our child:
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Health and Emergency Authorization Form

This form is intended to assure that your child will be able to receive proper medical care should he/she require it, even if you are not available at the time of need. In an emergency, we will first attempt to reach a parent or guardian.
Date form completed*

MonthDayYear
Date
Date of last physical exam*

MonthDayYear
Date
Child's Name*

First NameLast Name
Height*
Weight*
Date of Birth*

MonthDayYear
Date
MaleFemale
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number*
Please enter a valid phone number.
Parent's Phone Number*
Please enter a valid phone number.
Parent's Email*
example@example.com
Please provide TWO phone numbers/contacts that can be used in case of emergency during camp hours.
Contact 1*

First NameLast Name
Contact 1 Phone Number*
Please enter a valid phone number.
Contact 1 Relationship to Child*
Contact 2*

First NameLast Name
Contact 2 Phone Number*
Please enter a valid phone number.
Contact 2 Relationship to Child*
Child’s Endocrinologist

First NameLast Name
Endocrinologist phone number*
Please enter a valid phone number.
Child’s Primary Care Physician*

First NameLast Name
PCP phone number*
Please enter a valid phone number.
Insurance Company*
Insurance Identification or Policy #*
I/We, being the parent (s) or legal guardian (s) of the above-named minor, do hereby appoint Mary Washington Healthcare personnel (e.g. program manager, camp nurse, etc.) to act on my/our behalf in authorizing emergency medical, dental, or surgical care and hospitalization for the above minor during the period(s) of my/our absence.
Parent/Guardian 1*

First NameLast Name
Relationship to child*
Parent Signature 1*

Clear
Parent/Guardian 2

First NameLast Name
Relationship to child
Parent signature 2

Clear

Medication Administration Form

List all medications, including nutrition supplements, even if not given at camp.

If you would prefer to print out this page to bring to your child's physician, please click here and download the PDF. It needs to be turned in by May 29, 2025.

NOTE: Any medications brought to camp must be in their original container and properly labeled. All medications will be stored on site and administered by the camp staff. The Medication Administration Form must be filled out completely. Please list all medications. If your child takes liquid medications, please remember to include the medicine spoon.
I will fill out the medication form*

OnlineDownloaded PDF
Child's Name

First NameLast Name
DOB

MonthDayYear
Date
Physician's Name

First NameLast Name
Physician's Phone Number
Please enter a valid phone number.
List all medications, including dosage, time and frequency. Also indicate if this medication will need to be given at camp.
I/We authorize the personnel of Mary Washington Healthcare Diabetes Management Program/Kids for a Cure Day Camp to administer listed medications and treatment to my child during the time of camp as per my/our physician’s instructions as listed above.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date

Pick-up Information

Please list the designated person or persons that will be authorized to pick up your child following camp’s conclusion.
Child's Name*

First NameLast Name
Authorized person 1*

First NameLast Name
VA driver's license # (1)*
Authorized person 2*

First NameLast Name
VA driver's license # (2)*
Authorized person 3

First NameLast Name
VA driver's license # (3)
Date*

MonthDayYear
Date
Signature of Parent/Legal Guardian*

Clear

Release of Liability and Assumption of Risk

Please read this form carefully and be aware that by signing and participating in this program you will be assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you or your minor child/ward might sustain as a result of participating in any and all activities connected with and associated with this program, including transportation services to and from Kids for a Cure Day Camp.

I recognize and acknowledge that there are certain risks of physical injury to participants in the Kids for a Cure Day Camp, and I voluntarily agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that my minor child/ward or I may sustain as a result of participating in any and all activities connected with or associated with Kids for a Cure Day Camp.

I further agree to waive and relinquish all claims I or my minor/ward may have (or accrue to me or my child/ward) as a result of participating in any program/activity against Kids for a Cure Day Camp including its owner, participants, agents, volunteers, and employees.

I do hereby fully release and forever discharge Kids for a Cure Day Camp from any and all claims or injuries, damages, or loss that my minor child/ward or I may have, or which may accrue to me or my minor child/ward and arising out of, connected with, or in any way associated with Kids for a Cure Day Camp.

I have read and fully understand the above important information, warning of risk, assumption of risk, and waiver and release of all claims.
Camper Name*

First NameLast Name
Camper DOB*

MonthDayYear
Date
Date*

MonthDayYear
Date
Parent's Signature*

Clear

Wednesday Pool Day

Pick up at the pool will be at 2:30 p.m. More information to follow.
Please check the response that best describes your child’s swimming ability:*

My child has good swimming skills and is comfortable in water over his/her headMy child is a fair or a non-swimmer and needs to stay in water that is no more than chest deepMy child cannot swim and needs to stay in the shallow end of the pool
Additional comments:
Child's Name*

First NameLast Name
DOB*

MonthDayYear
Date
Date*

MonthDayYear
Date
Parent/Guardian Signature*

Clear

Consent to Photograph and Interview
I First Name* Last Name* consent to having photographic, video, electronic, audio media or interview conducted of myself, my child, or for the person(s) for whom I am responsible (name(s): First Name* Last Name* .)
I consent / decline (choose one) that my first name, the first name of my child(ren) and/or the person(s) for whom I am responsible be shared for the use in the publication, education or audio-visual program listed above.*

ConsentDecline
I consent / decline (choose one) to having friends, family and/or the caregiver interviewed regarding my condition, the condition of my child(ren), and/or the condition of the person(s) for whom I am responsible.*

ConsentDecline
I consent / decline (choose one) to having general information regarding my condition, the condition of my child(ren), and/or person(s) for whom I am responsible released by a Mary Washington Healthcare spokesperson, and if applicable, to law enforcement personnel conducting official investigations.*

ConsentDecline
I consent / decline (choose one) to having general information regarding my condition, the condition of my child(ren), and/or person(s) for whom I am responsible released by a Mary Washington Healthcare spokesperson, and if applicable, to law enforcement personnel conducting official investigations.*

ConsentDecline
I hereby release Mary Washington Healthcare, its subsidiaries, its personnel, my friends, family, caregiver and any persons participating in my care, the care of my child(ren) or the care of the person(s) for whom I am responsible from any and all liability that may or could result from the taking or the use of this media, release of general information by a Mary Washington Healthcare spokesperson and release of information to law enforcement personnel.*

Clear
Note: If the above patient is an unemancipated minor (under the age of 18), the above consent is given on the patient’s behalf by:*

Clear
Witness*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Kids for a Cure Camp

Camp Guidelines

Camp Rules

Diabetes Information

Health and Emergency Authorization Form

Health History

Allergies

Medication Administration Form

Pick-up Information

Release of Liability and Assumption of Risk

Wednesday Pool Day

Consent to Photograph and Interview