Diabetic Information Form – Day Camp

Please provide additional information regarding student's Type 1 Diabetes diagnosis. Based on responses SEACAMP San Diego may ask for additional information and/or a Physician's Release for Activities.

Student Name *

Select Program

Spring Break Camp

SEACAMP Jr.

Select Session Date

April 1 - 5, 2024

SEACAMP Jr. Session Date *

Date of Type 1 Diabetes Diagnosis

Date of Last Diabetic Emergency, if any

Description of Last Diabetic Emergency, if any

Student manages diabetes through use of

Insulin pump

Injecting medications

Food choices

OtherOther

As the parent/guardian of above student

I certify that student is self-sufficient at starting new pump sites and will be able to be off the pump for up to 2 hours – this is a necessity when participating in water activities.

As the parent/guardian of above student

I understand student will be away from medication access for as long as 2 hours - this is a necessity when participating in water activities. I further understand that student will be solely responsible for the administration of medications.

As the parent/guardian of above student

I understand student is required to bring proper food options to maintain appropriate levels while at camp.

Further describe how student manages diabetes *

As the parent/guardian of above student *

I understand SEACAMP San Diego does not have a Registered Nurse on staff to hold or administer prescription medications or assist with diabetes management. SEACAMP instructors are trained to recognize a diabetic emergency and we are within in a 9-1-1 service area.

Is student able to self-manage diabetes care? (i.e. checking blood sugar levels, making responsible food choices, managing medications and/or pump, cleaning/sanitizing materials, etc.) *

Yes, my child is able to self-manage diabetes care and child will be able to safely participate program and all activities.

No, but will be able to self-manage by the start of camp session and child will be able to safely participate program and all activities.

Parent/Guardian Signature

Electronic Signature Consent

I Accept - by selecting “I Accept,” you are signing this Agreement electronically. You acknowledge you have read and understand the above terms, and you agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. Click here for the full Electronic Signature Consent agreement.

As the parent/guardian of above student who is now a minor: *

I verify the above information provided is true and accurate and affirm that I am at least 18 years old with my signature below.

Parent/Guardian Name *

Parent/Guardian E-Signature *

Clear

Date of E-Signature

04/25/2024

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Diabetic Information Form - Day Camp

Parent/Guardian Signature