Camp Trios 2022 Application

Camper Registration

COVID-19:
We will follow the CDC guidance for day camps during Camp Trios (if COVID restrictions are required). We will send an email update the week before camp with the latest requirements.

WHO: Children ages 6 to 14 with type 1 diabetes

WHAT: Learning & having fun!

WHERE: Southridge Sports Complex, (Tri-City Court Club)
2901 Southridge Blvd, Kennewick, WA 99337

WHEN: Tuesday July 19th 8:30 am to 4:30 pm
Wednesday July 20th 8:30 am to 4:30 pm
Thursday July 21st 8:30 am to 4:30 pm

Question Title

* 1. Registration Checklist
All checklist items are due June 30, 2022

Completed application with signed consent

Signed authorization to treat

A head shot photo of your child: email to shannon.march@trioshealth.org

$75.00 payment *Please ask for scholarship application if unable to cover fee. Please remit payment to: Trios Health Diabetes and Nutrition Education 3730 Plaza Way, Suite 6600, Kennewick, WA 99338

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* 2. Camper Registration Information

Camper Name

Nickname

Address

City/Town

State/Province

ZIP/Postal Code

Camper's Birth Date

Email Address

Phone Number

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* 3. Sex

Male

Female

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* 4. Parent/Guardian

Name

Child's age at Diabetes onset

Address

City/Town

State/Province

ZIP/Postal Code

Child's age at camp

Email Address

Phone Number (please include cell number and best way to contact you)

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* 5. Other person(s) authorized to pick child up or contact in case of emergency

Name:

Relationship:

Phone Number:

Name:

Relationship:

Phone Number:

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* 6. Insurance information:
In the event of any need for medical care outside of the camp setting, insurance information for your child may be needed. Please complete the following:

Insurance Company Name:

Address:

Policy Number:

Name of Insured Family Member:

Insured Member's Place of Employment:

Is pre-authorization required?

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* 7. Tell us about your child:
Would you describe the camper as one who (check all that apply)

Is Sensitive

Makes Friends Easily

Is Moody

Is Easygoing

Is Easily Led

Is Strong-willed

Leads Others

Is Rebellious

Is Fearful

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* 8. Does your child get along with others?

Yes

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* 9. Is your child excited about coming to camp?

Yes

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* 10. Can your child swim?

Yes

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* 11. Is there any information that would help us ensure your child has the best camp experience possible?

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* 12. T-Shirt Size:

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult X-Large

Adult XX-Large

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* 13. Medical Information:
Does your child use an insulin pump?

Yes

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* 14. If yes, what brand and model:

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* 15. Does your child usually give own insulin injections or use pump without assistance?

Yes

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* 16. List name of insulin used:

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* 17. Carbohydrate ratios:

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* 18. Correction Factors:

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* 19. Blood glucose targets for correction factors:

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* 20. Does your child bolus before or after meals?

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* 21. Will your child need help with blood glucose tests?

Yes

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* 22. Has your child ever had seizures?

Yes

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* 23. Does your child recognize signs of low blood sugar?

Yes

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* 24. What are the usual symptoms of low blood sugar for your child?

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* 25. Will your child need to take any other medication besides insulin during camp hours?

Yes

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* 26. Please list any other medications, dosage, & schedule for your child:

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* 27. Please list specific accommodations needed or other health concerns we should be aware of:

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* 28. Camp Menu
July 19: Sandwich Bar
July 20: Taco Bar
July 21: BBQ

*menu will have gluten free options

NOTE: Two snacks a day and all entrees will include fruit, vegetable and water

Food allergies or special accommodations to menu:

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* 29. CONSENT:
I hereby give my consent for adjusting insulin dose, injecting insulin, performing blood tests, or any medical care deemed necessary by camp physicians, nurses and dietitians. I will not hold liable Camp Trios, Trios Health or any individual associated with the Camp, for accidental injury or illness resulting from this camper’s attendance and camp activities. 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.

Signature of Parent/Guardian:

Date:

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* 30. Camp Trios publicity Release Form:
Trios Health, and/or the local news media (i.e., TV, newspaper, radio) has my permission to take my child's picture, and/or interview my child, for local news stories while my child is a participant of Camp Trios.

I understand that I may or may not appear, or be mentioned, in said news story and require no financial or other remuneration for this. I understand that I have the right to rescind during taping or filming, not after the product is completed.

Release applies to dates of Camp Trios only – July 19, 20 and 21, 2022
Trios Health staff will oversee all interviews and photos.

Name of Child:

Name of Parent/Guardian:

Signature of Parent/Guardian:

Address:

Phone Number:

Camp Trios is committed to making a difference in the lives of children with diabetes, ensuring that they have the opportunity to live a healthy life and enjoy a safe environment to gather while learning to be self-disciplined and responsible.

Camp Trios 2022 Application

Camper Registration

Question Title

* 1. Registration ChecklistAll checklist items are due June 30, 2022

Question Title

* 2. Camper Registration Information

Question Title

* 3. Sex

Question Title

* 4. Parent/Guardian

Question Title

* 5. Other person(s) authorized to pick child up or contact in case of emergency

Question Title

* 6. Insurance information:In the event of any need for medical care outside of the camp setting, insurance information for your child may be needed. Please complete the following:

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* 7. Tell us about your child:Would you describe the camper as one who (check all that apply)

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* 8. Does your child get along with others?

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* 9. Is your child excited about coming to camp?

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* 10. Can your child swim?

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* 11. Is there any information that would help us ensure your child has the best camp experience possible?

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* 12. T-Shirt Size:

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* 13. Medical Information:Does your child use an insulin pump?

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* 14. If yes, what brand and model:

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* 15. Does your child usually give own insulin injections or use pump without assistance?

Question Title

* 16. List name of insulin used:

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* 17. Carbohydrate ratios:

Question Title

* 18. Correction Factors:

Question Title

* 19. Blood glucose targets for correction factors:

Question Title

* 20. Does your child bolus before or after meals?

Question Title

* 21. Will your child need help with blood glucose tests?

Question Title

* 22. Has your child ever had seizures?

Question Title

* 23. Does your child recognize signs of low blood sugar?

Question Title

* 24. What are the usual symptoms of low blood sugar for your child?

Question Title

* 25. Will your child need to take any other medication besides insulin during camp hours?

Question Title

* 26. Please list any other medications, dosage, & schedule for your child:

Question Title

* 27. Please list specific accommodations needed or other health concerns we should be aware of:

Question Title

* 28. Camp MenuJuly 19: Sandwich BarJuly 20: Taco BarJuly 21: BBQ*menu will have gluten free optionsNOTE: Two snacks a day and all entrees will include fruit, vegetable and waterFood allergies or special accommodations to menu:

Question Title

Question Title

* 1. Registration Checklist
All checklist items are due June 30, 2022

* 6. Insurance information:
In the event of any need for medical care outside of the camp setting, insurance information for your child may be needed. Please complete the following:

* 7. Tell us about your child:
Would you describe the camper as one who (check all that apply)

* 13. Medical Information:
Does your child use an insulin pump?

* 28. Camp Menu
July 19: Sandwich Bar
July 20: Taco Bar
July 21: BBQ

*menu will have gluten free options

NOTE: Two snacks a day and all entrees will include fruit, vegetable and water

Food allergies or special accommodations to menu: