Camp Application

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* Required information.
Personal Information
Camper's Name *
Nickname If your child has a nickname he/she prefers to be called by, enter it here.
Address *
City, State, Zip *
Camper's Birth Date *
Camper's Sex *
Has your child attended Camp Hots Shots before? If yes, how many years? *
Phone Numbers - Home - Work - Cell * Please list all phone numbers i.e. Home, Work, Cell.
Mother's Full Name *
Address if different from above
Mother's Employer? *
Email * Email address for correspondence and contact during camp hours
Father's Full Name: *
Address if different from above
Father's Employer? *
Email * Email for correspondence and contact during camp hours
Emergency Contact Number *
List name and phone numbers of persons authorized to pick up child *
Additional Information
Child's age at onset? *
How would you describe your child * Check all that apply. For multiple answers, hold CTRL key and click on each answer.
Does your child get along with others? *
Is your child excited about attending Camp Hot Shots? *
Can your child swim? *
Your child's T Shirt Size *

Transportation to and from camp will be provided from Omaha, NE at Westside Community Education Center (3534 S. 108th Street).
Departure time is 8:15am and will return at 4:45pm each day.

Will your child need transportation: *

INSURANCE

 

Name of Insurance Company and Policy Number *
Address of Insurance Company *
Name and social security number of insured family member: *
Insured member's place of employment *
Pre-authorization number if required.
Camper Diet Form

Please be sure to complete all appropriate sections of this form. This will ensure that all campers are given adequate food while at camp. It is also important that accurate information is given.  Please do not list what your prescribed meal plan is unless that is what you follow at least 3/4 of the time.  We want to know what you are actually eating.

Camper's Name and Age.
Name and Contact Information of Parent or Guardian.
Does the camper have any food allergies? If yes, please list and specify allergy and symptoms if exposed:
Please List all known food allergies and symptoms.
Does your child carry an EPI Pen for food allergy reactions?
Does your child have any other special nutrition needs?
If "YES", please specify (examples: gluten-free diet, lactose intolerance, etc.)

**If your child has food allergies or special nutrition needs, PLEASE contact chris@camphotshots.org and she will get you in contact with the dietician.

Current Snack Plan
Does the child wear an insulin pump?
Please choose which pump your child uses:

Current Snack Plan

PM Snack - List total number of Carbohydrates OR Insulin to Carb ratio, include correction factor:
When my child is at camp, I think they will: (choose one)

Current meal plan options:  PLEASE CHECK ONE:

We count carbohydrates and dose insulin based on what my child is going to eat.
My child eats a set amount of carbohydrates at each meal and snack.
Camp Hot Shots serves wholesome well-balanced meals.  We request parents DO NOT send food or beverages to camp.  Thank you!

Medical Information
Will your child need insulin during camp hours? *
Does child recognize signs of own low blood sugar?
Will your child need help with blood tests? *
How often does he/she have a blood sugar reaction?
What are the usual symptoms of low blood sugar for your child? *
Does your child usually give his/her own insulin injections without assistance? *
Is there a time of day your child is more likely to have low blood sugar reactions? *
Has your child menstruated? *
Has she been told about menstation? *
Has your child had any surgeries? Please explain surgery and dates: *
Ever lost consciousness? *
Hypoglycemia seizures? *
Medical Continued
What are the usual symptoms of low blood sugar for your child?
Will your child need to take any other medications besides insulin during camp hours? *
List name, dosage and time of day your child receives other medications:
Is your child allergic to ANY medications? (if Yes, describe)
Has your child ever been in diabetic ketoacidosis? If yes, last episode? *
Hives / Skin diseases? If yes, please describe. *
Poison Ivy? *
Athletes Foot? *
Does your child recognize signs of their own low blood sugar? *
NON INSULIN PUMP USERS

Please list current 24 hour insulin regiment.

Time of day Insulin taken:
Type of Insulin
Insulin: Carb Ratio
Correction Factor
Sliding Scale

______________________________________

Time of day Insulin taken:
Type of Insulin
Insulin: Carb Ratio
Correction Factor
Sliding Scale

__________________________________

Time of day Insulin is taken:
Type of Insulin
Insulin: Carb Ratio
Sliding Scale
Correction Factor

__________________________________

Time of day Insulin taken:
Type of Insulin
Insulin: Carb Ratio
Sliding Scale
Correction Factor

__________________________________________________________________

Time of day Insulin is taken:
Type of Insulin
Insulin: Carb Ratio
Correction Factor
Sliding Scale
INSULIN PUMP USERS
How long has your child been on an insulin pump?
Type of Pump?
Model of Pump?
Type of pump infusion set?
Type of insulin used in your child's pump?
How often is the infusion set changed?
Does your child know how to operate pump on their own?

List Basal Rates:

Time / Basal Rate
Time / Basal Rate
Time / Basal Rate
Time / Basal Rate
Time / Basal Rate

IF your child uses a different basal for "ACTIVE" days or uses a "Temporary" basal rate during sports / activities, please list here:

Time / Basal Rate or Temporary %
Time / Basal Rate or Temporary %
Time / Basal Rate or Temporary %
Time / Basal Rate or Temporary %
Time / Basal Rate or Temporary %

List insulin to carbohydrate ratio:

Units: Carbohydrate Grams: *
Lunch *
Units: Carbohydrate Grams: *
PM Snack - (if applicable)
Units: Carbohydrate Grams:
List Correction Factor: (i.e. add 1 unit of insulin for every 50 points over 150 blood sugar:

Please be attentive to having pump reservoirs adequately filled and batteries up-to-date. We can attend to emergency situations (i.e. sets coming loose or pulling out and taping issues) but would appreciate your attention to these other issues.

Camper Fee

Cost to attend Camp Hot Shots is $200.00

CHECK ONE

If you have a sponsor paying the fee for your child please fill out information below.

Sponsoring Organization
Contact Name
Address
City / State / Zip

I would like information on financial assistance. Campers are asked to seek financial assistance from civic organizations in their community prior to requesting financial assistance from Camp Hot Shots.

Please list at least three (3) organizations you have contacted for assistance. Include contact name.

Applications are due by May 1, 2017.  Applications are accepted on a first-come, first served basis. Please make sure all applicable spaces on your application are complete.

All campers must have a physical exam within three months prior to camp. Please make your appointment accordingly!

If you would like to make a tax deductible donation to Camp Hot Shots, please go to the donate page.

*** After you hit the "SEND" button you will need to download two forms. The Consent Form will need to be signed and dated by the parent / guardian and the child.    The Health History Form will need to be signed and dated by the Physician.