Name *

First Name

Last Name

Nickname or Preferred Name

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Camper's Birthdate

MM

DD

YYYY

Mother's Full Name

First Name

Last Name

Address (if different from above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Phone Number

Number to be reached during camp hours.

(###)

###

####

Father's Full Name

First Name

Last Name

Address (if different from above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's Phone Number

Number to be reached during camp hours.

(###)

###

####

Characteristics

Would you describe your camper as one whom: (select all that apply)

is sensitive

makes friends easily

is moody

is easy going

is strong willed

is easily led

leads others

Insurance Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Camper Fee: Cost of Camp Hot Shots *

Check one option below

I will pay online now (see link under Registration: Pay Camp Fee Online)

I will mail a check for $200 to Camp Hot Shots (P.O. Box 1731, Council Bluffs, IA 51502-1731)

I have a sponsor who will pay my fee

I am in need of a Sponsor.

I would like information on Financial Assistance

Campers are asked to seek financial assistance from civic organizations in their community before asking for financial assistance.

Yes

No

If yes, when was the last episode?

MM

DD

YYYY

Date of last physical exam:

MM

DD

YYYY

FOR SENSOR USERS

What type of sensor do you use?

Dexcom 6

Dexcom 7

Freestyle Libre 2

Freestyle Libre 3

Medtronic Guardian Sensor

What device(s) does your sensor read to?

Pump

Phone

Receiver

FOR PUMP-USERS

Please list the type and model of pump. Please be attentive to having pump reservoirs adequately filled for camp days and batteries up-to-date as we can attend to emergency situations (i.e. sets coming loose or pulling out, taping issues), but appreciate attention to these other issues.

Tandem Control-IQ

Tandem Basal IQ

Omnipod - Eros

Omnipod - Dash

Omnipod - 5

Medtronic 630

Medtronic 770

Medtronic 780

Consent

I hereby give my consent for adjusting insulin dose, performing blood tests, or any medical care deemed necessary by camp physicians and nurses. I also consent to photography/videography of my child to be used to publicize and raise funds for Camp Hot Shots. I will not hold liable Camp Hot Shots, Inc., or any individual associated with the Camp for any injury or illness resulting from this camper's attendance and activities at camp. I understand a camp setting is different than the home setting and management of my child's diabetes schedule, while medically supervised at camp, will need to be flexible. Applications will be accepted online and by mail. The application, payment, diet and health history form must be received and post marked by May 1st to be considered for camp.

Yes

No

Date of Signature

MM

DD

YYYY

Rules and Regulations

I hereby agree to obey all rules and regulations of Camp Hot Shots, Inc. I further agree to obey the instruction of camp counselors, physicians, nurses, and assistants pertaining to camp activities, medical needs or practices and all related matters. I also agree to inform the appropriate camp personnel of any mater or activity which I believe to be harmful or which creates the risk of accident or injury to myself or any other participant at the camp.

Yes

No

Date of Signature

MM

DD

YYYY