Camp Endres Sr Camper Info

General Information

Name*

First Last

Preferred name to be called?

Date of Birth*

MM

DD

YYYY

Sex*

Male
Female

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Age as of the First Day of Camp*

Grade Entering*

Father's Name

First Last

Father's Phone

Father's Place of Work

Mother's Name

First Last

Mother's Phone

Mother's Place of Work

Physician Information

Physician Name*

First Last

Office Phone*

Diabetes Physician's Name*

First Last

Office Phone*

Emergency Contact (if parent isn't available)

Name*

First Last

Phone*

Relationship*

Name*

First Last

Phone*

Relationship*

Health Insurance

Please upload a photo of the front & back of your child's insurance card*

Parent Questionaire

Completed By*

First Last

Relationship to Camper*

When was your camper diagnosed with diabetes?*

MM

DD

YYYY

Has your camper been a camper at Camp Endres before?*

Yes
No

Has your camper been a camper anywhere else before?*

Yes
No

If so, where?

Does your camper have experience with being away from home at night?*

Yes
No

Does your camper make friends easily?*

Yes
No

Does your camper have any reservations about coming to Camp Endres?*

Yes
No

If so, please explain

Does your camper have any siblings?*

Yes
No

If so, how many?

Has your camper expressed or experienced any of the following in the past year?

These answers are not a determinate on if your child can attend Camp Endres. It is important for us to know so we can best serve and care for your child so they can have the best camp experience.

"Having diabetes makes me feel like an outcast"*

Never
Rarely
Sometimes
Often
Always

"Having diabetes makes me angry"*

Never
Rarely
Sometimes
Often
Always

"I feel like my diabetes causes me to miss out on the things I want to do"*

Never
Rarely
Sometimes
Often
Always

"I have trouble talking about my diabetes to others"*

Never
Rarely
Sometimes
Often
Always

"I don't like to talk about my feelings towards diabetes to my family"*

Never
Rarely
Sometimes
Often
Always

"I am embarrassed about having diabetes"*

Never
Rarely
Sometimes
Often
Always

"I feel judged by others because I have diabetes"*

Never
Rarely
Sometimes
Often
Always

"I feel like no one understands how I feel because of diabetes"*

Never
Rarely
Sometimes
Often
Always

"I am self conscious about my weight"*

Never
Rarely
Sometimes
Often
Always

Has you child displayed signs of disordered eating*

Yes
No

Has there been a major life change in the past year?*

Yes
No

Has your camper moved schools in the past year?*

Yes
No

Has there been a divorce in the family within the past year?*

Yes
No

Has there been a death in the family within the past year?*

Yes
No

Please select all that describe your camper*

Shy & generally quiet most of the time
Shy at first but then open up
Outgoing from the get go
Highly active & always moving
Outspoken & loves to give their opinion
Soft spoken & tends to be more of an observer
Strong leader & tends to pressure others into things
Inactive & tends to pick indoor activities & ones less physically demanding

What do you hope your camper gains from their experience at Camp Endres?*

Are there any additional concerns or comments that we should know about regarding your camper?*

Does your camper have any cabin requests (to be with or not be with certain campers and or counselors)?*

Requests are made when possible, but we cannot guarantee that they will be made.

History and General Health

Height*

Weight*

Is your camper allergic to any medications?*

Yes
No

If so, please list

Is your camper allergic to any food?*

Yes
No

If so, please list

Date of Last Tetanus*

MM

DD

YYYY

Does your camper have any limitations to physical activity?*

Yes
No

If so, please explain

Has your camper had any recent exposure to infectious disease?*

Yes
No

If so, please explain

Does your camper have any other illnesses NOT including diabetes?*

Yes
No

If so, please list

Has your camper been hospitalized, been injured or had any surgeries in the past year?*

Yes
No

If so, please list

Has your camper been diagnosed with anxiety or depression?*

Yes
No

Has your camper been admitted to a mental health facility within the past 3 years?*

Yes
No

If so, please explain why and when they were there

Once again, this does not mean your child will not be able to attend Camp Endres, we just want to assure that they have the best camp experience.

Medications

To better serve your camper, we trust that you will keep your camper on all medications during the time that they are with us.

List of medications, including dosage and frequency. Please do not include insulin

Diabetes Information

What CGM will your child be wearing at camp, if they are not going to be wearing a CGM please select "not wearing CGM"*

Not wearing a CGM
Dexcom G5
Dexcom G6
Freestyle Libre
Medtronic Enlite

Please know that your child will not be allowed to use their phone as their receiver at Camp Endres

Please list the serial number of your camper's CGM device

What insulin is your camper on?*

NovoLog
Humalog
FIASP
Tresiba
Apedria
Lantus
Levimir

Will you be on an insulin pump or multiple daily injections at camp?*

Insulin Pump
Multiple Daily Injections

What time does your camper take their long acting insulin if they are on multiple daily injections?

: HH

MM

If your camper is on a pump, which pump do they use?*

Not on a pump
Animas
Medtronic
Omni Pod
Tandem

If your camper is on a pump, what is the serial number?

Please upload the Camper A1C Report here

Consent*

I agree to the liability disclosure statement

I hereby give consent for my camper to attend Camp Endres at the CENTRAL OKLAHOMA CAMP & CONFERENCE CENTER and participate in all activities associated with camp and:

Liability Disclaimer: …Hold harmless Diabetes Solutions-OK, Inc. and Central Oklahoma Camp & Conference Center, its associates, its agents, volunteers and employees, from any and all liability of whatsoever nature and from injuries, sickness, or other damages suffered by us or camper during his or her participation with diabetes camp. I/We further authorize and grant to Diabetes Solutions-OK, Inc., its associates, its agents, volunteers and employees, the right to take pictures of said camper during his or her participation with diabetes camp, and use the same for the purpose of creating educational films, and brochures, including use in news releases, and/or other publications, and we release you from any liability therefore.

Medical Disclaimer: …Understand there will likely be changes made in my camper’s insulin doses and food intake in attempts to prevent unusually low or high blood sugars. It will be my responsibility to contact my camper’s physician, nurse, etc. for additional questions and/or any recommendations for changes in the diabetes treatment plan following the camp.

Authorization for Medical Treatment: …Acknowledge this health history is correct so far as I/we know and my camper has permission to engage in all prescribed camp activities except as noted by myself or our physician. In the event I cannot be reached in an EMERGENCY, I hereby authorize the physician selected by the camp medical director(s) to hospitalize, secure proper treatment for, and to order injection, anesthesia, blood and blood products, or surgery for my son/daughter.

Field Trip Permission: …Give permission for our camper to travel from Central Oklahoma Camp & Conference Center within a 30 mile radius for field trips as part of the Camp Endres experience. I realize transportation will be provided by the Putnam City School busses and campers and staff will travel as a group specifically arranged by Camp Endres.

I/We, the undersigned parents and/or legal guardian of above named camper, have read and understand the above statements concerning described liability disclaimer, medical disclaimer, and authorization for medical treatment.

Consent*

Camper Contract

As the participating camper, I have read the rules listed below and understand that it is my responsibility to follow these rules. If I choose not to, I will be dealt with appropriately by the staff.
1) I will RESPECT the grounds and facilities, my fellow campers and staff and their possessions.
2) I will be PREPARED for the routine daily activities as scheduled and will PARTICIPATE in these (this includes blood glucose monitoring, insulin dosing, meals and snacks, and program activities) according to my needs and abilities.
3) I will WORK hard at having a great time, meeting new friends and sharing my time and talents with others.
4) I realize that the use of recreational drugs, any form of tobacco including vapes and juuls, and alcohol or prescription meds not prescribed for me is NOT permitted.
5) I will NOT steal or take things that are not mine and I will report those who do.
6) I realize that if I do not follow the above stated rules, I may no longer be permitted to participate in ANY future camping programs under the sponsorship of Diabetes Solutions-OK, Inc.

Camp Endres Senior Camper Information Packet

General Information

Physician Information

Emergency Contact (if parent isn't available)

Health Insurance

Parent Questionaire

Has your camper expressed or experienced any of the following in the past year?

History and General Health

Medications

Diabetes Information