Please don t hesitate to call if you have any questions. I can be reached at (603)

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1 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, , or mail) No Later Than Friday June 8, One of the educators will call your parents to go over the paperwork prior to camp. Please return the enclosed date/time preference sheet with the rest of the paperwork. Please plan to arrive for camp at 8:30 a.m. each day. Follow the camp signs in the parking lot for drop off behind the building. You will be greeted and escorted to our tent. Each morning, have your parent check in with one of the educators. If someone else is dropping you off, please ask your parents to send in your morning blood sugar and insulin dose. When your parents pick you up, they will go through your blood sugars from the day with one of the educators and then sign you out of camp. Important Information: Please label all of your belongings. We will provide all monitoring supplies, so please leave your meter at home. We must use one time use disposable lancets for safety reasons. Please bring your Humalog or Novolog pen (labeled with your child s name in a zip lock bag) and we will keep it for the week to use at camp. We will supply pen needles. If on a pump, please bring extra pump sets, reservoirs, or pods. We have food for treating low blood sugar (Juice, peanut butter crackers, or rice cakes for gluten free). Please leave all electronic devices and cell phones at home Please note the following special events: Beach day Wednesday (rain date Thursday) Theme Day Thursday Wear camp T-shirts Beach Day & Friday (handed out the morning of the beach) Family picnic Friday We will be having a family gathering on Friday. Please ask your family to arrive at 11:30 for a picnic. They are welcome to bring a blanket and their lunch. We will provide ice cream sundaes for dessert. The picnic will be followed by closing activities to end by 2:00 p.m. You are welcome to stay at the pool and swim with your family after the closing activities. Please don t hesitate to call if you have any questions. I can be reached at (603) Please return paperwork via Fax at , by to Kris.Ferullo@wdhospital.com or mail to: Wentworth-Douglass Hospital Diabetes Services 789 Central Avenue Dover, NH Look forward to seeing you at camp! Kris Kris Ferullo RN, CDE Nurse Manager Diabetes Services

2 CAMP HOT SHOT 2018 June 25-29, 2018 Child s Name: Date of Birth: / / Parent/Guardian(s) Name: Mailing Address: Home Phone Number: Contact number during program running time: address: Alternate Pick up: Relationship: Contact number during program running time: Please list child s medical diagnosis (if any): Child s dietary restrictions, special needs, or physical limitations: Child s allergies (if any): Has the participant been treated or hospitalized in the last 24 months? If yes, for what injury or illness? Authorization to Administer Medication I authorize appropriately qualified program staff of Wentworth-Douglass Hospital to administer the following medications, including over the counter medications, to my child: (please send with child) Medication _ Amount Times Insulin Per ratios/scale per schedule Glucagon 1 mg emergency only I give permission for my child to share our contact information with other campers: Yes No Parent/Guardian Signature: Date: / /

3 Child s Name: Date of Birth: / / GENERAL: Date of Diabetes Diagnosis Height Weight Immunizations up to date? (circle one) Y N Explain: Is there anything specific that your child would like to learn this week? Any issues that would be important for Camp Staff to know about? Y N Explain: DIET TYPE: Carbohydrate Counting Other: Food allergies? Food & Symptoms: BLOOD SUGAR: How often they check their blood sugar? (Times): Meter type: Last Hemoglobin A1C (date/result): What # is their blood sugar when they feel low? Ever had glucagon? Y N Date: Symptoms of low blood sugar: Symptoms of high blood sugar: Am Snack Lunch Pm Snack Insulin Schedule Ins:CHO ratio or insulin dose: Correction factor: am snack? (circle) Y N lunch? (circle) Y N pm snack? (circle) Y N Target BS: Snack Scale OR Lunch Scale MEDICATON: Pump Regimen Basal Times Insulin: Carbohydrate Ratio Correction Factor Target BS Rates Adjust dose prior to activity/swimming? (circle) Y N Instructions: Parent/Guardian Signature: Date: / /

4 Release I agree not to bring any claim or suit against Wentworth-Douglass Hospital and The Works Family Health & Fitness Center on behalf of my child for any injury or harm sustained by any event short of a criminal act, and then only the criminal shall be the subject of such a claim. I further agree that I will not cause to be brought, or encourage, a claim or suit. I also agree not to cooperate in the bringing of such a suit or claim except insofar as I may legally be required to do so. Finally, I shall indemnify Wentworth-Douglass Hospital and any and all defendants covered by this agreement for all judgments, costs, attorney fees, and other expenses incurred as a result of a breach of this agreement. In consideration for your purposes, objectives, and work, and in consideration of your permission to participate in the Diabetes Services Children s program, on behalf of myself, my heirs, executors, administrators, and assigns, I hereby waive and release any and all rights and claims for damages which I may have against you, as well as any other person connected with the program, their executors, administrators, successors, and assigns for any and all injuries which my child may suffer while taking part in the event or result thereof. I hereby give my permission to representatives of the Diabetes Services Children s program to render usual and customary healthcare, including medication as needed, based on the instructions received from family based on the child s home schedule, as represented under Authorization to Administer Medication. I understand that any part of my child s medical records may be used for medical care and related purposes. In addition, in the case of an emergency, I authorize program staff to obtain necessary medical care. Responsibility for Medical Expenses The undersigned hereby agrees to be solely responsible for all medical and health expenses incurred in any way in connection with the attendance and participation at this program, including but not limited to those incurred in connection with travel to or from the location. The undersigned agrees to indemnify and hold harmless Wentworth-Douglass Hospital and The Works Family Health & Fitness Center on any claim or liability for payment of such medical or health expenses. Photo Authorization/Release I hereby grant full permission for organizer to use photographs of participation in legitimate accounts and promotions of Wentworth-Douglass Hospital programs (brochures, magazine, WDH social media channels, presentations, etc.). Durability This document is effective from the date signed for one year. Parent/Guardian Signature: Date: / /

5 Camp Hot Shot Field Trip Permission Slip I authorize my child (First & Last name) to participate in a Camp Hot Shot Field trip to Newcastle Beach on Wednesday June 27, 2018 with a rain date of Thursday June 28, The group will depart from The Works Family Health & Fitness Center at 8:30 a.m. and return at 4:00 p.m. I understand that the children will be transported by bus. I hereby release the staff and directors of Camp Hot Shot, Wentworth-Douglass Hospital, and/or the bus company from any claims for losses due to personal injury or property damage that may occur during the field trip. (Parent/Contact Name) is available at home/work during the field trip and can be reached at (Phone Number). I authorize emergency medical treatment in the event that it is needed as indicated on The Child Registration and Emergency Information Form. Parent/Guardian Signature: Date: / / (check if applicable) I will be transporting my child to and from Newcastle Beach and will meet the group there at 9:15 a.m. and pick my child up at 3:00 p.m.

6 Diabetes Camp Phone Call Dates & Times As mentioned in the welcome letter, we will be calling before camp to review the enclosed information. Please let us know your time preference for a phone call. (Check ALL that would work for you) Child & Parent s name: Phone # to call: Monday June 11 th Tuesday June 12 th Wednesday June 13th 12:30 p.m. 4 p.m. 2:30 pm 6 pm 8 a.m. 1 p.m. Friday June 15th Monday June 18th Wednesday June 20th 9 a.m. 3 p.m. 8 a.m. 12 p.m. 8 a.m. 4 p.m. 1 p.m. 4:30 p.m. To assist with our planning for the family gathering on Friday June 29, 2018 please indicate the number of people who will be attending (include your camper, all family members are welcome). # attending Friday gathering (Including camper)

7 What to Bring to Camp? Please remember to label ALL belongings with child s name REQUIRED: Hearty lunch including sources of protein & carbohydrate, 2 snacks and drinks packed in an insulated container. (See RD letter for more on the subject of food) Please provide CARB content of non-packaged items written on item or on a list in lunch box. Water bottle (cool water refills available) Sneakers and socks are MANDATORY every day. Sandals are for pool time ONLY Sun Screen We will be spending a lot of time outdoors! Bathing Suit & Towel o Optional: Water shoes or sandals for in and around the pool (Children have scraped their feet in the past) Goggles to avoid eye irritation Please bring a lifejacket if your child is not a strong swimmer but still would like to swim (The Works will not provide them)! Sweat shirt or jacket: Please dress for the weather, it can be quite variable: hot, cold, and rainy! Extra set of play clothes Art smock or large T-shirt to protect clothes during craft projects Electronic game systems Ipods, etc. Cell phones DO NOT BRING

8 Dust off the old camp t-shirts because Tuesday is T s on Tuesday If you are feeling creative we have a batch of extras you can take and make into something new from that old t-shirt or shirts! New to camp? You can grab one of the extras too. Check in with us on 1 st day of camp.

9 Hypoglycemia Protocol These are general guidelines, treatment may vary depending upon the situation mg/dl = If prior to active activity, ½ cup juice mg/dl = ½ cup juice; also 2-4 P.B.C if more than ½ hour before meal or snack <60 mg/dl = 1 cup juice; also 4 P.B.C. if more than ½ hour before meal or snack Re-Checking: Recheck minutes after a low prior to resuming activity Recheck BS before swimming or strenuous activity if a low earlier. *Rice cakes and peanut butter for children with celiac *Cheese & crackers for children with peanut allergy