Camp Trios 2021 Application

Camper Registration

COVID-19:
We will follow the CDC guidance for day camps during Camp Trios. 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 20th 8:30 am to 4:30 pm
Wednesday July 21st 8:30 am to 4:30 pm
Thursday July 22nd 8:30 am to 4:30 pm

Question Title

* 1. Registration Checklist
All checklist items are due June 30, 2021

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

Address 2

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

Address 2

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 Social Security Number:

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 20: Subway
July 21: Costa Vida
July 22: 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 20, 21 and 22, 2021
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 2021 Application

Camper Registration

Question Title

* 1. Registration ChecklistAll checklist items are due June 30, 2021

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:

Question Title

* 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?

Question Title

* 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:

Question Title

* 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 20: SubwayJuly 21: Costa VidaJuly 22: 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, 2021

* 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 20: Subway
July 21: Costa Vida
July 22: 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: