CANDY Camp Application

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