Kids for a Cure Summer Day Camp June 19-22, :30am-3:00pm Fredericksburg Presbyterian Church Downtown Fredericksburg

Transcription

1 Diabetes Management Program Kids for a Cure Summer Day Camp June 19-22, :30am-3:00pm Fredericksburg Presbyterian Church Downtown Fredericksburg Requirements for Junior Counselor: Age 13 and 14 Teacher s written recommendation Documentation of previous experience with children Availability to help at camp on following dates: Previous diabetes camp experience (as camper) Responsible diabetes management T-Shirt size form Cost: $75 Will need MD orders, photography form and liability forms filled out Application due by May 26, 2017

2 Name: Age Mailing Address: Telephone Numbers: Medical Orders Signed by Physician (See Enclosed) Please mail application to: Cathy Peterjohn, RD, CDE 4710 Spotsylvania Parkway Suite 200 Fredericksburg, VA It may be ed with desired recommendations and documentation as attachments to

3 RELEASE OF LIABILITY AND ASSUMPTION OF RISK Please read this form carefully and be aware that in signing and participating in this program you will be expressly 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. PLEASE PRINT: Participant s Name: Date: Participant s Signature (Parent/Guardian MUST sign for a participant under age 18) Please return by May 26, 2017

4 Please Mark your Counselor s T-Shirt Size Name of Counselor Youth Size Large (14-16) Adult Sizes Small Medium Large

5 Wednesday Pool Day Fredericksburg Country Club We will leave the Church at 10:45 am and travel by Trolley to the pool. We will be able to start swimming at 11am. We have hired 2 additional lifeguards for safety (3 on duty already). Each child will be assigned to a counselor and an adult for supervision. Lunch will be served at 12noon. Please pick up your child at the Fredericksburg Country Club at 2:30pm. Please circle the correct answer that describes your child s swimming ablility: My child is able to swim the 25yards(length of the pool) without stopping Y N My child can swim the length of the pool with some difficulty Y N My child cannot swim and needs to stay in the shallow end of the pool Y N Additional comments Parent Signature

6 KFC June 19-22, 2017 Camp Staff For Camp Publicity or MWHC Publication

7 2017 Kids for a Cure Club Day Camp Physician s Approval and orders-pump Child s Name: Age: I certify this child is physically fit to participate in all the activities of Kids for a Cure, the Diabetes Day Camp being co-sponsored by Mary Washington Hospital s Diabetes Management Program. The child listed above is my patient and I have been treating him/her for diabetes since. Please indicate insulin type: Please indicate insulin pump type: Basal rates: Bolus rates: Insulin to CHO ratio s: Is Insulin Given For Snack? Is A Correction Given At Snack? Is Insulin Given For Lunch? Is A Correction Given At Lunch? Correction Factor: Target blood sugars: MD Signature: Print Address/phone Orders must be signed and received by June 11, 2017 in order for child to attend camp.

8 2017 Kids for a Cure Club Day Camp Physician s Approval and Orders- Injections Child s Name: Age: I certify this child is physically fit to participate in all the activities of Kids for a Cure, the Diabetes Day Camp being co-sponsored by Mary Washington Hospital s Diabetes Management Program. The child listed above is my patient and I have been treating him/her for diabetes since. Please indicate the patient s insulin orders: Insulin type/dosage: Target sugars: Correction factor: Sliding Scale: Is Insulin Given For Snack? Is A Correction Given at Snack Is Insulin Given For Lunch? Other orders or comments about patient care: Physician Signature: Physician s name/address/phone (please print) Orders must be signed and received by June 11, 2017 in order for the child to attend camp.