Medical Update and Waivers Step 1 of 3 33% HiddenEmail Camper Name(Required) First Last I confirm that my child has not been in contact with or had any communicable disease in the 10 days before camp unless noted here (e.g. COVID, chicken pox, head lice, diarrhea, impetigo, strep throat, etc.)(Required) No, my child has not been in contact with communicable disease(s) Yes, my child has been in contact with communicable diseases Please explain How active has your camper been in August?(Required) Not very active Somewhat active Very active Unsure How sensitive is your camper's blood glucose to activity?(Required) Not very sensitive Somewhat sensitive Very sensitive Unsure How often has your camper been having lows in the last couple of weeks?(Required) If your camper has lows, when do they usually happen? Has your camper had any lows during the night in the last couple of weeks? Yes No Unsure How does your camper take insulin?(Required) Injections Pump How does your camper monitor blood glucose?(Required) Continuous Glucose Monitor (CGM) Freestyle Libre Fingerstick testing only Would you like your camper to do a trial of a Dexcom or Libre monitor at camp?(Required) Yes No Do you have a preference for which?(Required) Dexcom Libre It doesn't matter Do you have a smart device that you can provide your camper with?(Required) I have access to a device for my camper I do not have access to a device and will need a reader Dexcom CGMs require a smart device (iOS/Android) to pair with. The device does not require cell service or data, only Bluetooth. If your camper doesn't have a smart device at camp, then we will provide you with a Libre that comes with its own reader. How many times a day do you give insulin?(Required) 2 3 4 or more What type of insulin does your camper currently take?(Required) NPH N Lantus Levemir Basalgar Tresiba Tuojeo NR H Apidra Fiasp Admelog Please select all that applyDoes your camper...(Required) Use carb targets for meals Use a sliding scale Use a correction factor We don't use carb targets, sliding scale, or correction factor. Please select all that applyWhen giving insulin, do you...(Required) Give the same base dose of rapid insulin (plus a sliding scale) each day? If so, write the base dose of rapid insulin in the boxes below for each time it is given. Use a ratio to vary the base dose of insulin according to how much is eaten. (If so, write a ratio in the boxes below as 1:x. For example, if the ratio is 10, write 1:10). I'm unsure NPH/N dosage informationPlease fill in the details of your camper's daily NPH or N dosage.AMAM SnackNoonPM SnackDinnerBedtime Add RemoveLantus/Levemir/Basalgar/Tresiba/Tuojeo dosage informationPlease fill in the details of your camper's daily Lantus/Levemir/Basalgar/Tresiba/Tuojeo dosage.AMAM SnackNoonPM SnackDinnerBedtime Add RemoveNR/H/Apidra/Fiasp/Admelog dosage informationPlease fill in the details of your camper's daily NR/H/Apidra/Fiasp/Admelog dosage.AMAM SnackNoonPM SnackDinnerBedtime Add RemoveSliding scale or ISFPlease enter your sliding scale or ISF information (for example, does it go up by 0.5 or 1 units?)AMAM SnackNoonPM SnackDinnerBedtime Add RemoveCorrection factor (CF) informationPlease write in the number for your camper's correction factor (CF).AMAM SnackNoonPM SnackDinnerBedtime Add RemoveCarb target informationPlease fill in your camper's carb target information (in grams).AMAM SnackNoonPM SnackDinnerBedtime Add RemovePump type(Required) Medtronic 630G Medtronic 670G Medtronic 770G t:slim Omnipod Other Auto mode? Yes No Basil-IQ or Control-IQ? Basal-IQ Control-IQ Other Home and camp pump patternsHome pattern nameCamp pattern name Add RemovePlease set up a new profile called “Camp”. This way, at the end of camp, you can easily change back to your usual settings if we make changes during the week. If your camper tends to be low with activity, we suggest lowering the settings by 10-20%. Otherwise, just set up a duplicate profile called camp. Home Pump PatternIt would be helpful for us if you would upload your pump before camp. If you do this, you do not need to fill in the table below.BasalsUse one entry per row for time and rate of insulin, starting at midnight. If you have uploaded your pump, you do not need to fill in this section. Click the "+" to add new lines.TimeRate Add RemoveRatiosUse one entry per row for time and ratios, starting at midnight. If you have uploaded your pump, you do not need to fill in this section. Click the "+" to add new lines.TimeRatio Add RemoveTarget BGUse one entry per row for time and target, starting at midnight. If you have uploaded your pump, you do not need to fill in this section. Click the "+" to add new lines.TimeTarget Add RemoveISFUse one entry per row for time and ISF, starting at midnight. If you have uploaded your pump, you do not need to fill in this section. Click the "+" to add new lines.TimeISF Add RemoveHave you uploaded your pump?(Required) Yes Not yet, but I will No, I will not be able to do this. I have filled out the settings above What is the name on the account that you upload pump settings to? First Last Consent, Liability, and Waiver(Required) I agree to the waiver and consent to participate release for Camp Banting.I, on my own behalf and in my capacity as the parent or guardian of my registered camper at Camp Banting (collectively the Applicant Family), and in consideration of the recreational and educational services provided by Camp Banting agree as follows: 1. I hereby release and discharge Camp Banting, their respective agents and employees from all manner of action, causes of action, claims or demands our Applicant Family may have, arising from or related to our attendance at camp notwithstanding that any such loss, injury or damage may have arisen by reason of the negligence of the Camp Banting, its servants, agents or employees. 2. I agree to indemnify Camp Banting, its services, agents or employee, from any claims or demands made against Camp Banting in respect to any loss or damage which they may suffer or become legally obligated to pay as a result of, or arising from the attendance of our Applicant Family at camp. 3. I consent to the administration of medical treatments on behalf of the children as is determined to be necessary by Camp Banting, its servants, agents or employees, in their sole discretion, for his/her health by the camp. 4. I certify that all information provided in registration forms I complete for the Camp Banting program is true to the best of my knowledge at the time of completing these forms. 5. I have reviewed the Behaviours Expectations & Policies and I understand that should our Applicant family breach any of the expected behaviours, they could be expected to leave the camp program immediately. If this instance occurs, no refund of fees will be made available and I will be responsible for arranging our transportation from camp and the associated costs. 6. I acknowledge that we are aware that the Camp Banting program provides risk-taking and potentially hazardous outdoor pursuit programs, which could include, but are not limited to boating, swimming, hikes, games, or other activities that involve physical activity and the possibility of injury resulting from such activity. I acknowledge that the camp facility may contain physical hazards that may result in injury or death to persons or damage to property on or at the facility. 7. I acknowledge that it is the policy of Camp Banting to take all reasonable precautions to ensure children and staff safety with respect to such activities and to provide a safe environment. 8. On behalf of the Applicant Family, I freely consent to all such risks and fully assume all responsibility for the possibility of personal injury, death, disability, property damage or loss resulting thereof, howsoever caused, with the sole exception being gross negligence on the part of Camp Banting, their staff, their members, agents, employees and directors. I further waive and release any and all claims that our Applicant Family have or may have in the future, against Camp Banting as a result of the participation at a Camp Banting Program. This consent shall be effective and binding on our Applicant Family, heirs, next of kin, executors or administrators. I have read and understood this consent and I am aware that by signing it I am waiving certain legal rights which I, the applicant and our heirs, next of kin, executors or administrators may have.Media Consent I agree to the media consentDuring the camp program, there may be pictures, films, video and other media relating to our Applicant family. As well, promotional materials involving various media may include my child. On behalf of our Applicant family, I hereby agree that Camp Banting may use and publish any of the foregoing with respect to our Applicant family, so long as no information identifying our Applicant family is included with any such media, and I hereby also specifically agree to the terms of the release as follows. I hereby consent and agree that Camp Banting, its successors, administrators or assigns (hereinafter referred to collectively as “Camp Banting”) have the right to publish my/our story, comments and/or photograph, film and/or video of our Applicant Family (collectively the “Material”) for use in Camp Banting’s campaigns, promotions, advertisements and in any other way that furthers Camp Banting’s objectives. I understand that the Material may be published in any and every form of media in both domestic and foreign markets and may be included in whole or in part, in colour or in black and white. I hereby release and discharge Camp Banting and all persons acting under Camp Banting’s permission or authority or those for whom Camp Banting is acting from and against any liability resulting from the foregoing use of the Material or from any distortion, blurring, alteration, and/or use in composite form, whether the same is intentional or otherwise, that may occur in the taking of, processing, reproduction, or presentation of the Material. I hereby waive my right to inspect and/or approve the finished story, comments and/or photograph, film or video in whatever media the Material may be used or the eventual use to which the Material may be applied. As part of the release, I hereby assign to Camp Banting any copyright that I may have in the Material, and also specifically waive any moral rights that I may have with respect to the Material. I have read the foregoing release and warrant that I fully understand the contents thereof. It is understood that my/our identity may be used by Camp Banting when publishing/releasing information as noted in this document.Signature(Required)Please sign in this box to acknowledge you have read Camp Banting's releases and waivers.
