Camp Endres Senior Camper Information Packet General InformationName* First Last Preferred name to be called? Date of Birth* Month Day Year 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 PhoneFather's Place of Work Mother's Name First Last Mother's PhoneMother's Place of Work Physician InformationPhysician 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 InsurancePlease upload a photo of the front & back of your child's insurance card*Max. file size: 32 MB.Parent QuestionaireCompleted By* First Last Relationship to Camper* When was your camper diagnosed with diabetes?* Month Day Year 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 HealthHeight* 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* Month Day Year 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.MedicationsTo 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 InformationWhat 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? : Hours Minutes AM PM 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 hereMax. file size: 32 MB.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 ContractAs 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.