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 Sponsors: Healthworks! North North Mississippi LLC & University Medical Center (3) Camp Dates: June 18 th June 21 st, 2018 (4) Location: Healthworks! NMMC LLC 219 S. Industrial Road, Tupelo, MS 38801 General Information (Camper) [Camper s Name]: [Camper s Preferred Name]: (First) (Middle) (Last) [Date of Birth]: / / [Age]: Biological Sex: Male Female [Street Address]: (MM) (DD) (YYYY) Gender: Boy Girl [City]: [State]: [County]: [Zip Code]: [School Camper Attends]: [Entering Grade]: Page 1 of 13 Policy or Form Number: NMMC 2018 Form Series # 9.01.0001
General Information (Parent #1) [Name]: [Relationship to Camper]: (First) (Middle) (Last) Legal Authority for Camper?: Yes No [Home Phone]: ( ) [Work Phone]: ( ) [Cell Phone]: ( ) [E-mail]: General Information (Parent #2) [Name]: [Relationship to Camper]: (First) (Middle) (Last) Legal Authority for Camper? Yes No [Home Phone]: ( ) [Work Phone]: ( ) [Cell Phone]: ( ) [E-mail]: Page 2 of 13 Policy or Form Number: NMMC 2018 Form Series # 9.01.0001
Emergency Contact(s) In the event of an emergency, please supply the names of additional persons which we can contact in the event that we are unable to reach the listed Parent(s)/Guardian(s). MUST SUPPLY TWO (2) Emergency Contacts. Emergency Contact #1 [Name]: [Relationship to Camper]: (First) (Middle) (Last) [Home Phone]: ( ) [Cell Phone]: ( ) Emergency Contact #2 [Name]: [Relationship to Camper]: (First) (Middle) (Last) [Home Phone]: ( ) [Cell Phone]: ( ) Please Continue to Next Page: Additional Information Page 3 of 13 Policy or Form Number: NMMC 2018 Form Series # 9.01.0001
Additional Information Previous Camp Attendance (a) Has your child previously attended a Diabetes Camp? If yes, when and where: Activity Restrictions (a) Do you anticipate any restrictions on activities for your child while at camp? If yes, please explain: Emotional, Psychological, Behavior Issues () Does your child have any emotional, psychological, or behavioral issues? () If yes, does your child take medication for the issue(s)? Please Explain: Please Continue to the Next Page: T-Shirt Sizing & Scholarship Page 4 of 13 Policy or Form Number: NMMC 2018 Form Series # 9.01.0001
T-SHIRT SIZE & SCHOLARSHIP T-SHIRT SIZE (Please Circle One) YOUTH: SMALL MEDIUM LARGE NOT AVAIL. NOT AVAIL. ADULT: SMALL MEDIUM LARGE XL XXL Scholarship Do you wish to apply for a scholarship? Yes No If so, please complete the attached Scholarship Application form on page 12. Please continue to the next page: Camper Health History. Page 5 of 13 Policy or Form Number: NMMC 2018 Form Series # 9.01.0001
CAMPER HEALTH HISTORY Allergies: If your child has known food allergies, please list the foods known to cause the reaction: FOOD: REACTION: FOOD: REACTION: FOOD: REACTION: For additional food allergies, please attach a list to this application. Is your child allergic to any medications? Yes No If Yes, please list the medications: Has your child ever had an allergic reaction to latex? Yes No Physician Information Name of Primary Care Physician/Pediatrician: Physician s Address: [City]: [State]: [ZIP Code]: Page 6 of 13 Policy or Form Number: NMMC 2018 Form Series # 9.01.0001
CAMPER HEALTH HISTORY (CONT.) Surgeries & Injuries Nature and Date of Any Surgeries or Injuries: (Please Circle) Nature of Event (Surgery or Injury) (a) Injury, (b) Injury Requiring Surgery, or (c) Surgery (a) Injury, (b) Injury Requiring Surgery, or (c) Surgery (a) Injury, (b) Injury Requiring Surgery, or (c) Surgery (a) Injury, (b) Injury Requiring Surgery, or (c) Surgery (a) Injury, (b) Injury Requiring Surgery, or (c) Surgery (a) Injury, (b) Injury Requiring Surgery, or (c) Surgery Date Disability/Chronic/Recurring Illness Does your child have any disability or disabilities or chronic/recurring illness? If so, please list: Page 7 of 13 Policy or Form Number: NMMC 2018 Form Series # 9.01.0001
Medical Conditions: Does your child have any of the following conditions listed below? (a) Nasal/Sinus Yes No Explain: (b) Skin Condition Yes No Explain: (c) Convulsions/Seizures Yes No Explain: (d) Heart Disease Yes No Explain: (e) Glasses/Vision Yes No Explain: (f) Hearing Loss Yes No Explain: (g) Prosthesis Yes No Explain: Additional Medical Conditions: Does your child have any medical conditions in addition to or other than the ones listed above? If so, explain below. Page 8 of 13 Policy or Form Number: NMMC 2018 Form Series # 9.01.0001
Medications Please list all medications in the space provided below. Name Dose Frequency Indication Additional Medical Information: Is there any additional medical information we should know about your child? Page 9 of 13 Policy or Form Number: NMMC 2018 Form Series # 9.01.0001
Diabetes History Name of Endocrinologist: Date of Diagnosis: / / Does the Camper have a Continuous Glucose Monitor ( CGM )? Yes No Medtronic Dexcom Does your child take insulin shots or use an insulin pump? Insulin Shots Insulin Pump Does your child take any oral diabetes medication? If so, when and how much? FOR INSULIN SHOTS ONLY: Name of Long Acting Insulin: Name of Mealtime Insulin: FOR INSULIN PUMP ONLY: Pump Brand: Infusion Set: Insulin Brand Novolog Humalog Apidra Has your child been hospitalized in the past year due to diabetes? Yes No If yes, how many times? Has your child been to the ER in the past year due to diabetes? Yes No If yes, how many times? Page 10 of 13 Policy or Form Number: NMMC 2018 Form Series # 9.01.0001
CAMP AGREEMENT AND CONSENT I understand that my child shall observe the same camp rules which apply to all other children present. I also understand that if my child fails to adhere to camp rules, I may be contacted to pick up my child from Camp Sugarhouse Rock. I understand that in signing this form, I consent to my child being photographed, videotaped and that such photographs or videos may be used for the purpose of recording the camp experience. Further, I understand that these photographs or videos may be used in the following manner(s): (a) publicity, whether through print, broadcast, or social media, (b) fundraising, and (c) other purposes by North Mississippi Medical Center, University of Mississippi Medical Center, or their sponsors. In the event that I, or the emergency contacts listed, cannot be contacted within what medical staff considers a medically reasonable period of time, I give my consent for medical staff to provide medication(s) deemed necessary in order for the physician in charge to render emergency medical care to my child. I understand that my child must be covered under our own medical accident insurance. A copy of Proof of Insurance Certificate or Medical Care is attached. In consideration of the services, which are rendered to the child named above, pursuant hereto, the following is a listing of any insurance policies we have in force for said child: Insurance Company: Policy: Group: Medicare: Medicaid: Child s Name: This authorization shall be effective until the conclusion of the camp period. Parent/Guardian: Signature of Parent/Guardian: If there are any questions or comments, please call Children s of Mississippi Tupelo Specialty Clinic at (601) 815-3575 and Press Option 0, OR e-mail kstone2@umc.edu. Page 11 of 13 Policy or Form Number: NMMC 2018 Form Series # 9.01.0001
CAMP SCHOLARSHIP APPLICATION Annual Household Income? Household Size? Why do you feel that this camp would be beneficial for your child? Optional: If your child would like to write about why he or she would like to come to camp, please do so here. Page 12 of 13 Policy or Form Number: NMMC 2018 Form Series # 9.01.0001
FOR OFFICE USE ONLY Camp Fee: Cash: Check: Money Order: Registration Fee: Cash: Check: Money Order: Scholarship Granted: Yes No Amount: Picture: Yes No Physician Form: Yes No Parent Consent Form: Yes No Insurance, Proof of: Type = Page 13 of 13 Policy or Form Number: NMMC 2018 Form Series # 9.01.0001