Diabetic Information Form - School Year Diabetic Information Form - School Year Please provide additional information regarding student's medical condition. Based on responses SEACAMP San Diego may ask for additional information and/or a Physician's Release for Activities. Student Name * School/Group * Specify Medical Condition * Date of Diagnosis * Date of Last Medical Emergency related to this medical condition, if any Description of Last Medical Emergency related to this medical condition, if any If last event is within 1 year, students will be required to have a physician’s signature on the following physician’s release form in order to participate in Field Activities. As the parent or 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 either within in a 9-1-1 service area or radio access to the Coast Guard when out on field activities (ie boat trip, if applicable). As the parent or guardian of above student * I have looked at the schedule of events for my student’s camp attendance. My child will be able to adjust diabetic regimen to account for the activity level of the camp schedule with the assistance of parent or school chaperone. As the parent or guardian of above student * I understand SEACAMP San Diego is an “unplugged” experience for students throughout the session and students will not have access to wi-fi when at camp. I understand the use the electronic devices are only allowed to be used to manage diabetes and must be kept away or kept with a parent/school chaperone when not in use. I have discussed this policy with my student. My child is currently using some technology to assist with management of diabetes. * Yes No List forms of technology that are being utilized * My child manages diabetes through use of * Insulin pump Injecting medications Food choices OtherOther As the parent/guardian of above student * I certify that my child is self-sufficient at starting new pump sites or is able to start a new pump site with the assistance of a parent or school chaperone 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 certify that my child is self-sufficient at injecting medications or is able to start a new pump site with the assistance of a parent or school chaperone and will be able to be away from medication access for as long as 2 hours - this is a necessity when participating in water activities. Student Manages Diabetes Through Food Choices Please note our meals are provided by an outside caterer. Student is responsible for making good/appropriate food choices. Caterer is not able to provide carbohydrate counts for meals. As the parent/guardian of above student * I understand that my child is responsible for making good/appropriate food choices. Caterer is not able to provide carbohydrate counts for meals. My child will need low carbohydrate meals (carb amounts unspecified) during camp session(s) * Yes, my child would like low carb meals No, my child will eat regular meals 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 * signature keyboard Clear Date of E-Signature 07/26/2024 Submit If you are human, leave this field blank.
