CANDY Camp Application
|
|
- Katrina Rogers
- 5 years ago
- Views:
Transcription
1 CANDY Camp Application Please complete the following form and submit it by June 15, Please mail form to Bonnie Kruse, Diabetes Program Coordinator, HSHS St. Anthony s Memorial Hospital, 503 North Maple Street, Effingham, IL Camper Information: Camper Name: Nickname Guest Name: Camper Address: City: State: Zip: Home Phone Number ( ) Gender: Male Female Date of Birth: / / Age at Start of Camp: Grade Completed: Age at Diagnosis: Type of Diabetes Type 1 Type 2 Insulin Administration: Pen Syringe Pump Parent Information: Mother/Guardian Name: Address (if different from camper): Employer: Work Phone: ( ) Home Phone: ( ) Mobile Phone: ( ) Father/Guardian Name: Address (if different from camper): Employer: Work Phone: ( ) Home Phone: ( ) Mobile Phone: ( ) Health Care Provider Information Full name of camper s primary care physician: Physician s Address: City: State: Zip: Phone #: ( ) Emergency Contact Information other than parent (list only that person who will know how to reach you at all times) Name: Relationship: Home Phone: Work Phone: Diabetes Goals Does the camper participate in his/her own diabetes care? If so, what does he/she do? What new skills would the camper like to learn at camp?
2 Please summarize the personal care/supervision you feel your child will need at camp (other than routine diabetes management): Activities What does the camper enjoy doing? Any special skills or interests? Can camper swim? Yes No Does camper make friends easily? Yes No Insulin A.M. doses of insulin should be given before camp. Camper should bring his/her own supply of insulin if he/she receives a noon dose please label all supplies with camper s name. Pump patients should bring emergency supplies of insulin/reservoirs and additional infusion set. Does your child draw up or dial his own insulin injections? Yes No If using carb to insulin ratio or sliding scale, can your child calculate his/her own insulin dose? Yes No Insulin Units and Time of Administration (Insulin Pen or Syringe/Vial Users) Insulin (Circle the AM Noon PM Bedtime brand you use) Regular (Humulin R, Novolin R) Rapid Acting: Apidra, Humalog, Novolog Affrezza NPH (Humulin N, Novolin N) Lantus, Toujeo (Glargine) Levemir (Detemir) 70/30 (Humulin, Novolin, Novolog) Humalog 75/25 Humulin 50/50 Other Device: Pen Pump Syringe Does the camper use a pump Yes No If Yes, please complete the attached Pump User s Questionnaire. Blood Glucose Monitoring Does your child test his own blood glucose? Yes No How often does your child test at home: Type of Meter used Continuous Glucose Monitor (CGM)/Sensor Yes No Type of CGM
3 Hypoglycemia Low Blood Glucose: Never Occasional Frequent Does your child recognize signs of own Low Blood Sugar? Yes No What are the usual symptoms of a low blood sugar in your child? Hypoglycemic Reactions: Mild Severe Ever Lose Consciousness? Usual Time of Day reaction occurs Health Information Allergies Yes No List: List all medications other than insulin: Medication: Dosage: Frequency: Medication: Dosage: Frequency: Medication: Dosage: Frequency: Medication: Dosage: Frequency: Nutrition Besides diabetes, does the camper have any special dietary needs? Food Allergies: Food Avoidances: How much does your child understand about his/her nutrition plan? Check the appropriate statements Knows how to count carbohydrates Knows when to eat Knows what to take for low blood sugars Knows how to use exchange lists (if applicable) Knows how to weigh/measure foods Knows how to use insulin to carbohydrate ratio (if applicable) Please complete the following with the number of exchanges, carbohydrate choices or grams of carbohydrates at each meal that your child consumes as part of his meal plan. Breakfast Lunch Supper Total grams Carb OR Total grams Carb OR Total grams Carb OR Carb Choices OR Carb Choices OR Carb Choices OR : Carb to Insulin Ratio : Carb to Insulin Ratio : Carb to Insulin Ratio Mid Morning Mid Afternoon Bedtime Total grams Carb OR Total grams Carb OR Total grams Carb OR Carb Choices Carb Choices Carb Choices
4 What would your like your child to learn about diabetes and nutrition at camp? If you are sending a child without diabetes to Day Camp, please complete this portion of the questionnaire. How would you rate the nondiabetic child s knowledge of diabetes? Excellent Good Average Poor Does the nondiabetic child give support to the brother, sister, or friend, and cooperate in efforts to maintain good diabetic control? Yes No Some of the time Does the nondiabetic child have any medical problems which the Day Camp staff should be aware? Please explain What would you like the nondiabetic child to gain from this camp experience? Parent Signature Date
5 HOLD HARMLESS We, the undersigned, parents and/or legal guardians of, a minor, in consideration of the admission by St. Anthony's Memorial Hospital of said child to its summer day camp, hereby covenant and agree to save, defend, and hold St. Anthony's Memorial Hospital, its agents, servants, and employees, harmless from any and all claims of any kind, character or nature whatsoever, which may hereafter arise out of or in any way related to the attendance by said child at said summer camp, including, but not limited to, the generality of the foregoing, all claims arising out of the alleged negligence of St. Anthony's Memorial Hospital, its agents, servants, and employees. MEDICAL CONSENT If your child attends camp, I give my consent for blood glucose testing and whatever other medical care may be deemed necessary while my child is at camp. Date Parent or Legal Guardian FOR USE IN CASE OF EMERGENCY ONLY During the camp period from June to June, in case of emergency involving camper,, you can reach me: At my home address, which is: Name Address City & State Phone: ( ) OR THROUGH MY TRAVELING ITINERARY, WHICH IS ATTACHED OR THROUGH THE FOLLOWING PERSON, WHO WILL KNOW OF MY WHEREABOUTS: Name Address City & State Phone: ( ) PHOTO RELEASE FORM I,, hereby give my permission to St. Anthony's Memorial Hospital to photograph, videotape or audiotape me and to publish photographs or tapes of me, with or without my name. Publication may occur now or at any time in the future, may be in various forms of media (print television/radio, Internet) and may be for any editorial, promotional, advertising, trade or other purpose. Signed Date If the subject is under 18 years of age, the signature of a parent is also required: Parent/Guardian Date Office Use Only: Name of Newspaper Street Address, City, State, and Zip
6 Insulin Pump User s Questionnaire To be completed by camper and parent Camper Name: Type of Pump used name and model: Infusion Set Used: Insertion Device Used (if applicable): How long has the camper been on the pump? Is the camper familiar with the operation of his/her own pump? Yes No Please list your basal rates: Basal Rate #1 from Midnight to ; units/hour Basal Rate #2 from to ; units/hour Basal Rate #3 from to ; units/hour Basal Rate #4 from to ; units/hour Please list your insulin to carbohydrate ratios below: Breakfast : Mid Morning Snack : Lunch : Mid afternoon snack : Dinner : Bedtime Snack : What is your high glucose bolus ratio (correction or sensitivity factor) and goal (e.g. 1 unit per 50 mg/dl for BG>140)? When has the camper required a high glucose bolus besides mealtime? Does the camper experience any particular challenges with operation of the pump? What assistance does your child require in the operation of the pump?
7 CANDY Camp Non-Diabetic Guest Application Please complete the following form and submit it by June 17, Please mail form to Bonnie Kruse, Diabetes Program Coordinator, HSHS St. Anthony s Memorial Hospital, 503 North Maple Street, Effingham, IL Camper Information: Camper Name: Nickname Camper Address: City: State: Zip: Home Phone Number ( ) Gender: Male Female Date of Birth: / / Age at Start of Camp: Grade Completed: Parent Information: Mother/Guardian Name: Address (if different from camper): Employer: Work Phone: ( ) Home Phone: ( ) Mobile Phone: ( ) Father/Guardian Name: Address (if different from camper): Employer: Work Phone: ( ) Home Phone: ( ) Mobile Phone: ( ) Health Care Provider Information Full name of camper s primary care physician: Physician s Address: City: State: Zip: Phone #: ( ) Emergency Contact Information other than parent (list only that person who will know how to reach you at all times) Name: Relationship: Home Phone: Work Phone: If you are sending a child without diabetes to Day Camp, please complete this portion of the questionnaire. How would you rate the non-diabetic child s knowledge of diabetes? Excellent Good Average Poor Does the non-diabetic child give support to the brother/sister/friend and cooperate in efforts to maintain good diabetic control? Yes No Some of the time Activities What does the camper enjoy doing? Any special skills or interests? Can camper swim? Yes No
8 Does camper make friends easily? Yes No Does the non-diabetic child have any medical problems or allergies that the Day Camp staff should be aware? Please explain Please list any medications/dose/frequency the non-diabetic child may need during CANDY CAMP and send what the child needs during camp. What would you like the non-diabetic child to gain from this camp experience? Parent Signature Date
Supplemental Health Record and Authorization for Care of Child with Insulin Dependent Diabetes
477 Beaverkill Road Olivebridge, New York 12461 (845) 657-8333 Ext. 15 Fax (845) 657-8489 martin.bernstein@ashokancenter.org www.ashokancenter.org 2012-13 Supplemental Health Record and Authorization for
More informationDiabetes Medical Management Plan
of Plan: School year: Diabetes Medical Management Plan This plan should be completed by the student s personal health care team and parents/guardian. It should be reviewed with relevant school staff and
More informationCAMP INDEPENDENCE OF SAN ANTONIO 2017
CAMP INDEPENDENCE OF SAN ANTONIO 2017 Camp Independence will let the sunshine in as we celebrate Summertime during our 31 st edition of camp. will be held on the campus of St. Mary s Hall School from July
More informationDiabetes Medical Management Plan
Scotus Central Catholic High School 1554 18th Ave., Columbus, NE, 68601; 402-564-7165; FAX 402-564-6004; www.scotuscc.org Diabetes Medical Management Plan Date of Plan: Effective Dates: Student Name: Date
More informationParent Form DIABETES MEDICAL MANAGEMENT PLAN This form must be renewed each school year or with any change in treatment plan
Parent Form Student s PARENT CONSENT FOR We (I), the undersigned, the parent(s)/guardian(s) of the above named child, request that this Diabetes Medical Management Plan, and any modification thereto, be
More informationDate of birth: Type 2 Other: Parent/guardian 1: Address: Telephone: Home: Work: Cell: address: Camper physician / health care provider:
Day & Evening Camp 2018 Specialized Health Care Diabetes Medical Management Plan Must be completed if your camper has diabetes. Parent/guardian and physician signature required. **We will also accept copies
More informationTO BE COMPLETED BY LICENSED HEALTH CARE PROFESSIONAL
PART I OFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON DIABETES MEDICAL MANAGEMENT PLAN Page 1 of 5 TO BE COMPLETED BY PARENT OR GUARDIAN Student School Date of Birth Date of Diagnosis Grade/ Teacher Physical
More informationROBINSON INDEPENDENT SCHOOL DISTRICT 500 West Lyndale * Robinson, Texas (254) Fax (254)
ROBINSON INDEPENDENT SCHOOL DISTRICT 500 West Lyndale * Robinson, Texas 76706 (254) 662-0194 Fax (254) 662-0215 To the parents /guardian of : Your child has been identified as having diabetes. Robinson
More informationDiabetes Medical Management Plan
MADISON CONSOLIDATED SCHOOLS Diabetes Medical Management Plan Date of Plan: Effective Dates : The student s personal health care team and parents/guardian should complete this plan. It should be reviewed
More informationDiabetes Medical Management Plan
Date of Plan: Diabetes Medical Management Plan This plan should be completed by the student s personal health care team and parents/guardian. It should be reviewed with relevant school staff and copies
More informationDiabetes Medical Management Plan
Date of Plan: Diabetes Medical Management Plan Effective Dates: This plan should be completed by the student's personal health care team and parents/guardian. It should be reviewed with relevant school
More informationSCHOOL HEALTH PLAN: DIABETES
BRANDON FLORENCE MCLAURIN NORTHWEST PELAHATCHIE RANKIN COUNTY SCHOOL DISTRICT GREAT TO BEST PISGAH PUCKETT RICHLAND RANKIN COUNTY SCHOOL DISTRICT SCHOOL HEALTH PLAN: DIABETES of Plan: Effective s: This
More information9-A. Diabetes Medical Management Plan
of Plan: Diabetes Medical Management Plan This plan should be completed by the student s personal health care team and parents/guardian. It should be reviewed with relevant school staff and copies should
More informationVICTORIA INDEPENDENT SCHOOL DISTRICT Diabetes Medical Management Plan
VICTORIA INDEPENDENT SCHOOL DISTRICT Diabetes Medical Management Plan This plan should be completed by the student s personal health care team and parents/guardian. Student s Name: of Birth: of Diabetes
More informationDiabetes Medical Management Plan
Diabetes Medical Management Plan This plan should be completed by the student's personal health care team and parents/guardian. It should be reviewed with relevant school staff and copies should be kept
More informationDiabetes Medical Management Plan (DMMP)
Diabetes Medical Management Plan (DMMP) This plan should be completed by the camper s personal diabetes health care team, including the parents/guardian. It should be reviewed with relevant staff and copies
More informationHomeroom Teacher: Mother/Guardian: Address: Telephone: Home Work. Address: Father/Guardian: Address: Telephone: Home Work Cell: Address:
Community Unit School District No. 1 Diabetes Care Plan 6:120-AP4, E1 This plan should be completed by the student s personal diabetes health care team, including the parents/guardian. It should be reviewed
More informationFREEHOLD REGIONAL HIGH SCHOOL DISTRICT. Parents/Guardian of
FREEHOLD REGIONAL HIGH SCHOOL DISTRICT Parents/Guardian of In order to comply with N.J.S.A. 18A:40-12.11-21, which addresses the care of the diabetic student in the school setting, the attached packet
More informationCAMP LOCATIONS CAMP STAFF. You can be young, have diabetes and still have FUN. Exercise and a good diet should be part of your life
ELIGIBILITY Moses E. Cheeks Slam Dunk for Diabetes Basketball Camp is for children and young adults ages 5-18 years old who have been medically diagnosed with diabetes and prediabetes. Please submit your
More informationDiabetes Medical Management Plan
of Plan: Diabetes Medical Management Plan (Adapted for JHU/CTY Summer Programs) This plan should be completed by the student s personal health care team and parents/guardian. It should be reviewed with
More informationDate of Diabetes diagnosis Type I Type II. School Nurse Phone. Mother/Guardian. Address. Home phone Work Cell. Father/Guardian.
Diabetes Medical Management Plan/Individualized Healthcare Plan This plan should be completed by the student s physician, personal diabetes healthcare team and parent/guardians. It should be reviewed with
More informationMONMOUTH COUNTY VOCATIONAL SCHOOLS
Diabetes Medical Management Plan/Individualized Healthcare Plan Part A: Contact Information must be completed by the parent/guardian. Part B: Diabetes Medical Management Plan (DMMP) must be completed by
More informationDiabetes Medical Management Plan (DMMP)
Diabetes Medical Management Plan (DMMP) Page 1 of 7, DMMP This plan should be completed by the student s personal diabetes health care team, including the parents/guardians. It should be reviewed with
More informationLander County School District
Lander County School District of Plan: Diabetes Medical Management Plan This plan should be completed by the student s personal health care team and parents/guardian. It should be reviewed with relevant
More informationDiabetes Medical Management Plan
of Plan: Diabetes Medical Management Plan These orders remain in effect during the school day, school sponsored activities, and school sponsored overnight trips. This plan should be completed by the student
More informationT1D Camper s Name: Birth date: Gender: F M School Grade: Date Diagnosed: Insulin Type(s):
REGISTRATION FORM- T1D Camper + Optional Sibling/Friend Sam Fuld s USF Diabetes Sports Camp 2019 February 2-3, 2019 University of South Florida Athletic Fields Tampa, Florida Open to Campers Ages 8-17.
More informationVirginia Diabetes Medical Management Plan (DMMP)
Virginia Diabetes Medical Management Plan (DMMP) Adapted from the National Diabetes Education Program DMMP (2016) This plan should be completed by the student s personal diabetes health care team, including
More informationDiabetes Medical Management Plan/Individualized Healthcare Plan. Part A: Contact Information must be completed by the parent/guardian.
Middle School 908 689 0750 ext. 2020 WARREN HILLS REGIONAL SCHOOL DISTRICT Washington, NJ 07882 HEALTH OFFICES High School 908 689 3050 ext. 2 MS FAX 908 835 0570 HS FAX 908 835 8511 Diabetes Medical Management
More informationDiabetes Medical Management Plan (DMMP)
Diabetes Medical Management Plan (DMMP) This plan should be completed by the student s personal diabetes health care team, including the parents/guardian. It should be reviewed with relevant school staff
More informationWarren Township School District Diabetes IHCP
Warren Township School District Diabetes IHCP of Plan: Diabetes Health Management Plan This plan should be completed by the student s personal health care team and parents/guardian. It should be reviewed
More informationIndividual Health Care Plan-Diabetes
Individual Health Care Plan-Diabetes Effective Date: School Year: 20 to 20 This plan should be completed by the student s diabetes care aide/health clerk and parents/guardians. It should be reviewed with
More informationDiabetes Medical Management Plan (DMMP) Handout C.1
This plan should be completed by the child s personal diabetes health care team, including the parents/guardian. It should be reviewed with relevant program staff and copies should be kept in a place that
More informationStroke Hyperglycemia Insulin Network Effort (SHINE) Trial Treatment Protocols. Askiel Bruno, MD, MS Protocol PI
Stroke Hyperglycemia Insulin Network Effort (SHINE) Trial Treatment Protocols Askiel Bruno, MD, MS Protocol PI SHINE Synopsis Acute ischemic stroke
More informationDiabetes Medical Management Plan
SCHOOL DISTRICT OF LEE COUNTY HEALTH SERVICES Print Form Date of Plan Diabetes Medical Management Plan This plan should be completed by the student's personal health care team and parents/guardian. It
More informationSex: M/F Date Of Birth: YYYY / / MM DD Age: Mobility challenges: (wheelchair, crutches): Y/N Home Address:
CAMPER DETAILS First Names: Surname: Sex: M/F Date Of Birth: YYYY / / MM DD Age: Mobility challenges: (wheelchair, crutches): Y/N Home Address: Current School Grade: Name of School: T-Shirt Size: Kids
More informationAuthorization for MAT Diabetes Certified Staff to Administer Insulin and/or Glucagon
Medication Administration Training for Child Day Programs Handout B.1 Authorization for MAT Diabetes Certified Staff to Administer Insulin and/or Glucagon Child s Name: Child s Date of Birth: Child Day
More informationAPPENDIX #1: SAMPLE Diabetes Medical Management Plan (DMMP)
APPENDIX #1: SAMPLE Diabetes Medical Management Plan (DMMP) Date of Plan: Diabetes Medical Management Plan This plan should be completed by the student s personal health care team and parents/guardian.
More informationDiabetes Medical Management Plan (DMMP)
Diabetes Medical Management Plan (DMMP) This plan should be completed by the student s personal diabetes health care team, including the parents/guardian. It should be reviewed with relevant school staff
More informationTO BE COMPLETED BY LICENSED HEALTH CARE PROFESSIONAL
PART I OFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON DIABETES MEDICAL MANAGEMENT PLAN Page 1 of 5 TO BE COMPLETED BY PARENT OR GUARDIAN Student School Date of Birth Date of Diagnosis Grade/ Teacher Physical
More informationName: DOB: Date: School Year: _ _
DIABETES SCHOOL ORDER FORMS Instructions for completing school diabetes order forms: Parents are asked to complete as much as possible, including the skills assessment. Please do not return blank forms
More informationRancocas Valley Regional High School Diabetes Medical Management Plan
of Plan: Rancocas Valley Regional High School Diabetes Medical Management Plan Individualized Healthcare Plan/ 504 Plan will be completed by the school nurse in consultation with the student s parent /guardian
More informationDiabetes Medical Management Plan (DMMP)
Diabetes Medical Management Plan (DMMP) This plan should be completed by the student s personal diabetes health care team, including the parents/guardians. It should be reviewed with relevant school staff
More informationDiabetes Medical Management Plan
Diabetes Medical Management Plan 1 School District: School: School Year: Grade: Student Name: DOB: Provider Name: Phone #: Fax #: Blood Glucose Monitoring at School Blood Glucose Target Range: - mg/dl
More informationDear Parents/Guardians:
CEDAR MOUNTAIN PRIMARY SCHOOL P.O. Box 420/17 Sammis Road, Vernon, NJ 07462 Phone: 973-764-2890 Fax: 973-764-3294 Web: www.vtsd.com Dear Parents/Guardians: Rosemary Gebhardt, Principal rgebhardt@vtsd.com
More informationEMERGENCY CARE PLAN FOR DIABETES West Fargo Public School. Student Date Grade DOB Parent/Guardian Phone (H) BLOOD SUGAR TESTING
EMERGENCY CARE PLAN FOR DIABETES West Fargo Public School Student Date Grade DOB Parent/Guardian Phone (H) (C) (W) Does this student ride the bus: Yes No Preferred Hospital In Case of Emergency Physician
More informationA GUIDE FOR YOUR HEALTH, WELLNESS AND SAFETY
A GUIDE FOR YOUR HEALTH, WELLNESS AND SAFETY AFTER HOURS CARE holidays, weekends, nights 1. IF YOU ARE HAVING AN EMERGENCY, CALL 911 IMMEDIATELY. 2. Our normal business hours are Monday through Friday,
More informationCamp Sugarhouse Rock Camper Application
Camp Sugarhouse Rock Camper Application Note: This application is to be completed by a Parent or Guardian. Application Deadline, Camp Dates, & Location (1) Application Deadline: June 1 st, 2018 (2) Camp
More informationDIABETES MEDICAL MANAGEMENT PLAN (DMMP) School Year: Student s Name: Date of Birth:
DIABETES MEDICAL MANAGEMENT PLAN (DMMP) School Year: Student s Name: Date of Birth: BLOOD GLUCOSE (BG) MONITORING: (Treat BG below 80mg/dl or above 150 mg/dl as outlined below.) Before meals as needed
More informationLAKE CENTRAL SCHOOL CORPORATION Clark Middle School W. ss- Avenue, St. John, IN Phone (219) Fax (219) 365-9;348
LAKE CENTRAL SCHOOL CORPORATION Clark Middle School 8915 W. ss- Avenue, St. John, IN 46373 Phone (219) 365-9203 Fax (219) 365-9;348.;.f ;.:'~-,'F. -e g;' -i-. ~'. t1r. Scott Graber Mr. Ken Newton Mrs.
More informationDISCLAIMER: ECHO Nevada emphasizes patient privacy and asks participants to not share ANY Protected Health Information during ECHO clinics.
DISCLAIMER: Video will be taken at this clinic and potentially used in Project ECHO promotional materials. By attending this clinic, you consent to have your photo taken and allow Project ECHO to use this
More informationCare of Students with Diabetes
Care of Students with Diabetes To ensure that students with diabetes are provided a safe learning environment and are integrated into school activities, please refer to the link Nursing Guidelines for
More informationDiabetes Medica Management Pnan (DMMP)
Diabetes Medica Management Pnan (DMMP) This plan should be completed by the student's personal diabetes health care team, including the parents/guardian. It should be reviewed with relevant school staff
More informationNph insulin conversion to lantus
Nph insulin conversion to lantus Search 26-2-2003 RESPONSE FROM AVENTIS. We appreciate the opportunity to respond to Dr. Grajower s request for information regarding Lantus ( insulin glargine [rdna origin.
More informationDIABETES MEDICAL MANAGEMENT PLAN
Revised 10/2017 DIABETES MEDICAL MANAGEMENT PLAN The student s healthcare provider and parents/guardians should complete this form. Please fill out entire form. Review with relevant school personnel who
More informationDiabetes Medical Management Plan (DMMP) Adapted from Helping the Student with Diabetes Succeed: A Guide for School Personnel (2016)
Diabetes Medical Management Plan (DMMP) Adapted from Helping the Student with Diabetes Succeed: A Guide for School Personnel (2016) This plan should be completed by the student's personal diabetes health
More informationCare of Students with Diabetes
Care of Students with Diabetes To ensure that students with diabetes are provided a safe learning environment and are integrated into school activities, please refer to the link Nursing Guidelines for
More informationAdjusting Insulin Doses
Adjusting Insulin Doses Everyone with diabetes, including you, will need to adjust your insulin doses at some time. There are several reasons why a person may need an insulin adjustment. These reasons
More informationManaging Diabetes when you are having a colonoscopy
Managing Diabetes when you are having a colonoscopy Disclaimer This is general information developed by The Ottawa Hospital. It is not intended to replace the advice of a qualified health-care provider.
More informationPlease don t hesitate to call if you have any questions. I can be reached at (603)
WELCOME! Dear Camper, We re very happy you will be spending the week with us! We have LOTS of fun activities planned! Please ask your parents to fill out the enclosed paperwork and return it (by fax, email,
More informationRaising the Standard
DIABETES ACTION PLAN (Editable document) Directions: 1. To input data, click on the first blank line, type in information 2. Use tab key to advance to the next field 3. Check mark fields, use tab to advance
More informationDIABETIC MANAGEMENT PLAN
DIABETIC MANAGEMENT PLAN Parent Consent and Physician Authorization POWAY UNIFIED SCHOOL DISTRICT HEALTH SERVICES 15250 Avenue of Science, San Diego, CA 92128 Dear Parent/Guardian and Physician of California
More informationDisclosure 1/16/2017. Michael R. Brennan D.O., M.S., F.A.C.E Director Beaumont Endocrine Center Chief of Endocrine Beaumont Grosse Pointe 1/16/2017 2
Therapy For Diabetes Michigan Association of Osteopathic Family Physicians Mid-Winter Family Medicine Update Shanty Creek Resort, MI January 19-22nd 2017 Michael R. Brennan D.O., M.S., F.A.C.E Director
More informationstudent is independent staff to supervise student is independent staff to supervise student is independent staff to supervise student is independent
Diabetes Medical Management Plan This plan as well as school medication forms, self authorization and dietary forms should be completed by the student s personal health care team and parents/guardian.
More informationTechnology for Diabetes: 101 Basic Rules of the Road. Karen Hamon RN, BSN, CDE Stephen Stone MD, FAAP Neil H. White, MD, CDE
Technology for Diabetes: 101 Basic Rules of the Road Karen Hamon RN, BSN, CDE Stephen Stone MD, FAAP Neil H. White, MD, CDE Quick Pump Facts! o Constant insulin supply o Pager-sized mini-computer worn
More informationVirginia School Diabetes Medical Management Forms
Virginia School Diabetes Medical Management Forms Student School Effective Date Date of Birth Grade Homeroom Teacher Instructions: 1. Part 1- Contact Information and Diabetes Medical History. To be completed
More informationVirginia School Diabetes Medical Management Plan (DMMP) Part 1 Contact Information and Medical History
Virginia School Diabetes Medical Management Plan (DMMP) Part 1 Contact Information and Medical History Virginia Diabetes Council - School Diabetes Care Practice and Protocol - Provides guidelines, recommended
More informationCase Study: Competitive exercise
Case Study: Competitive exercise 32 year-old cyclist Type 1 diabetes since age 15 Last HbA1 54 No complications and hypo aware On Humalog 8/8/8 and Levemir 15 Complains about significant hypoglycaemia
More informationKate Jones, RD, CDE Camp Too Sweet Director
COVER PAGE Office Phone: 540-224-4360 Fax: 540-224-4357 In order to reserve your space, COMPLETED forms and payment in full must be received NO LATER THAN Friday, May 11, 2018. Applications received after
More informationDiabetes Self-Care Assessment Date:
Diabetes Self-Care Assessment Date: Personal Information: Name: Are you: Married Single Widowed Other Do you live: Alone with Spouse with Others Do you have any condition that affects your ability to take
More informationBROWNSBURG COMMUNITY SCHOOL CORPORATION
BROWNSBURG COMMUNITY SCHOOL CORPORATION HEALTH SERVICES 111 Eastern Avenue Brownsburg, IN 46112 (317) 852-1046 Fax (317) 852-1048 www.brownsburg.k12.in.us DIABETES MANAGEMENT PLAN for DOB School Name Year
More informationPoll Question 2. Special Boot Camp Workshop Beverly Dyck Thomassian, RN, MPH, BC ADM, CDE President, Diabetes Education Services.
Special Boot Camp Workshop Beverly Dyck Thomassian, RN, MPH, BC ADM, CDE President, Diabetes Education Services Poll Question 1 Mary takes 6 units lispro (Humalog) before dinner. Which BG result reflects
More informationZACHARY COMMUNITY SCHOOLS
PARENTAL CONSENT/ RELEASE OF INFORMATION/ AND STUDENT WITH DIABETES CONTRACT Student s Name D.O.B. Parent/Guardian Home Phone # Work/Cell Phone # School Teacher Grade Physician Office # Fax # 1. I give
More informationInsulin Basics. Bryan Primary Care Conference May 21, 2016 Shannon Wakeley MD Complete Endocrinology
Insulin Basics Bryan Primary Care Conference May 21, 2016 Shannon Wakeley MD Complete Endocrinology Disclosures Speakers Bureau for Sanofi, Astra Zeneca, Janssen, Boehringer-Ingelheim Objectives Discuss
More informationDiabetes Medical Management Plan (DMMP)
Diabetes Medical Management Plan (DMMP) Page 1 of 7, DMMP This plan should be completed by the student s personal diabetes health care team, including the parents/guardians. It should be reviewed with
More informationPARENT PACKET - DIABETES
School Year: Lexington-Fayette County Health Department SCHOOL HEALTH DIVISION 650 Newtown Pike Lexington, Kentucky 40508-1197 (859) 288-2314 (859) 288-2313 Fax PARENT PACKET - DIABETES Dear Parent/Guardian:
More informationAPPLICATION 2018 Confidence Camp for Kids Elementary Program
APPLICATION 2018 Confidence Camp for Kids Elementary Program For ages 5-11 Note: Applications will be reviewed based on the order received. Date: Child s Name Date of Birth Male Female Home Address City
More informationKids for a Cure Summer Day Camp June 19-22, :30am-3:00pm Fredericksburg Presbyterian Church Downtown Fredericksburg
Diabetes Management Program Kids for a Cure Summer Day Camp June 19-22, 2017 8:30am-3:00pm Fredericksburg Presbyterian Church Downtown Fredericksburg Requirements for Junior Counselor: Age 13 and 14 Teacher
More informationChesterfield County Public Schools Office of Student Health Services. Request for Individualized Healthcare Plan
Chesterfield County Public Schools Office of Student Health Services Request for Individualized Healthcare Plan Dear Parent/Guardian: Providing a safe, supportive and nurturing environment is a goal of
More informationBaa Hózhó Navajo Prep Math Summer Camp 2017
Math Summer Camp 2017 Application Packet Grades 7-12 May 30-June 3, 2017 Navajo Preparatory School, Farmington, NM Residential Camp Application Checklist A complete application must include the following:
More informationInsulin Pump Therapy. WakeMed Children s Endocrinology & Diabetes WakeMed Health & Hospitals Version 1.3, rev 5/21/13 MP
Insulin Pump Therapy WakeMed Children s Endocrinology & Diabetes Overview What is an insulin pump? What are the advantages and disadvantages of an insulin pump? Lifestyle Changes Food Management Exercise
More informationPatient Education Handouts Table of Contents 2013 General Diabetes Information Monitoring and Management
Patient Education Handouts Table of Contents 2013 We have highlighted some handouts that may be helpful for the new patient. Select the ones that are most useful to you. Avoid overwhelming the patient
More informationLEON COUNTY SCHOOLS DIABETES MEDICAL MANAGEMENT PLAN & NURSING CARE PLAN (School Year - ) Plan Effective Date(s):
Student s Name: LEON COUNTY SCHOOLS DIABETES MEDICAL MANAGEMENT PLAN & NURSING CARE PLAN (School Year -) Plan Effective Date(s): Date of Diabetes Diagnosis: Type 1 Type 2 School Name: Date of Birth: School
More informationGuidelines for the Care Needed for Students with Diabetes
Guidelines for the Care Needed for Students with Diabetes for the implementation of State Board of Education Rule 160-4-8-.18 Diabetes Medical Management Plans Version 1.2 Table of Contents (1) DEFINITIONS:...
More informationLearning Objectives. Perioperative SWEET Success
Perioperative SWEET Success PERIOPERATIVE SWEET SUCCESS PRESENTED BY: KENDRA MARTIN, RN, BSN, CDE JENNIFER SIMPSON, RN, BC-ADM, MSN, CNS Disclosure to Participants Notice of Requirements For Successful
More informationSHINE Study PowerChart Order Set CONTROL
SHINE Study PowerChart Order Set CONTROL Orders Patient Care Component Blood Glucose Details Hypoglycemia: For BG
More informationThe Society of St. Vincent de Paul. Riverwalk. San Marcos, TX
The Society of St. Vincent de Paul Riverwalk San Marcos, TX Saturday October 1, 2016 The Society of St. Vincent de Paul 624 East Hopkins Street San Marcos, Texas 78666 512-353-7394 River Walk for the Poor
More informationDIABETES MEDICAL MANAGEMENT PLAN (School Year )
DIABETES MEDICAL MANAGEMENT PLAN (School Year ) Student's Name:. Date of Birth: Diabetes D Type 1 : D Type 2 Date of Diagnosis : School Name: Grade Homeroom Plan Effective Date(s): CONTACT INFORMATION
More informationLantus levemir conversion
Lantus levemir conversion Search Learn about starting insulin-naïve patients with type 2 diabetes on Levemir. Read Important Safety & Prescribing Info on the HCP Website. Lantus and Levemir have a variety
More informationPremixed Insulin for Type 2 Diabetes. a gu i d e f o r a d u lt s
Premixed Insulin for Type 2 Diabetes a gu i d e f o r a d u lt s March 2009 What This Guide Covers / 2 Type 2 Diabetes / 3 Learning About Blood Sugar / 4 Learning About Insulin / 5 Comparing Medicines
More informationDIABETES MEDICAL MANAGEMENT PLAN (DMMP)
ESUBMIT Reset Form Print Form DIABETES MEDICAL MANAGEMENT PLAN (DMMP Date of Plan: This plan is valid for the current school year: 20 20 STUDENT INFORMATION Name DOB Type of Diabetes Insulin Program Type
More informationAPPLICATION FORM PILOT STUDY OF OMEGA-3 AND VITAMIN D IN T1D
Page 1 APPLICATION FORM PILOT STUDY OF OMEGA-3 AND VITAMIN D IN T1D INSTRUCTIONS: This application and the information you provide will be used to determine if you qualify to participate in a study of
More informationPharmacy Plan Guidance
Pharmacy Plan Guidance The pharmacy plan is a tool used during the site readiness process to develop and document the site-specific procedures for study drug ordering, labeling and dispensing for the SHINE
More informationInternational School Bangkok Diabetes Management Plan 2018/19
International School Bangkok Diabetes Management Plan 2018/19 Student Family Name: Given Names: Date of Birth (dd/mm/yyyy): Grade at ISB (2018/19): Date of Plan (dd/mm/yyyy): Mother s Name: Phone: Father
More informationMOVING ON... WITH DIABETES
MOVING ON... WITH DIABETES KNOWLEDGE & SKILLS SELF-ASSESSMENTS (AGES 13-16 YRS) DIABETES EDUCATOR/TEAM USER GUIDE PURPOSE Evaluates knowledge and skill level related to diabetes management. Directs further
More informationImportant Stuff. Basal Bolus What Adjustments? Pt weighs 80kg
Diabetes Boot Camp Class 4 Beverly Dyck Thomassian, RN, MPH, BC ADM, CDE President, Diabetes Education Services Special Insulin and Pattern Management Diabetes Education Services 1998-2015. All rights
More informationDiabetes Devices Workshop Angela Aldrich, PharmD, PhC April Mott, PharmD, PhC, BCPS Presbyterian Medical Group 28 January 2018
Diabetes Devices Workshop Angela Aldrich, PharmD, PhC April Mott, PharmD, PhC, BCPS Presbyterian Medical Group 28 January 2018 Pumps & Sensors & Meters, Oh My! A Tale of Two Meters Technology for glucometers
More information2016 Diabetes Management Plan
Early childhood education and care setting 2016 Diabetes Management Plan Insulin pump therapy [to be used in conjunction with Action Plan] Name of child: Date of birth: Name of centre: Age : This plan
More informationDiabetes: What You Need to Know
UW MEDICINE PATIENT EDUCATION Diabetes: What You Need to Know Discharge review before you leave the hospital We want to be sure that we explained your diabetes instructions well, so that you know how to
More information