!!BEFORE STARTING THIS APPLICATION!!

Make sure you have all of your information:

One application per child
Guardian contact name(s), number(s), email(s), address(es), and occupation/employer
Alternate contact name & number
Camper's food allergies, if any
Endocrinologist and pediatrician contact name(s), number(s), address(es)
Insurance information with insurance cards, prescription cards if any. (Front and back sides REQUIRED, email to camp@stjda.org)
Immunization Record with dates of vaccines (REQUIRED, email to camp@stjda.org)
Residential camp begins on Monday and ends on Saturday.
Day camps are four days long, running Monday through Thursday.
Siblings are eligible to attend Day Camps only

Please make sure you have plenty of time to complete the entire application. You will not be able to save your incomplete work and finish later. If you have all your documentation and information prepared, we estimate the application will take 15-20 minutes to complete.

1: Camp Selection —— 2: Personal Information —— 3: Review & Submit

Camp Freedom Sessions

Camper Information

Your Camper is…

Pre-Diabetic, Type 1 Diabetic....

Preferred Language

Name

First Name

Last Name

Date of Birth

YYYY

Gender

Current Grade in School

Or grade just completed if filling out this form during the summer

What is your camper's t-shirt size?

We will PRE-ORDER based on your selection so please be sure of your size.

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Camper's Email (not guardian)

Camper's Date of Diagnosis

When was your child diagnosed with diabetes?

YYYY

Does your camper have allergies?

Put "NKA" if your child does not have allergies.

Guardian 1 Information

Guardian 1 will be listed in the camper's file. By providing this information, you are giving permission to release camper information to Guardian 1

Name

First Name

Last Name

Relationship to Camper

Phone

Country

(###)

###

####

Guardian 1 Employer

Is Guardian 1 Address the same as Camper's

yes

Guardian 2 Information

Name

First Name

Last Name

Phone Number

Country

(###)

###

####

Guardian 2 Email

Relationship to Camper

Alternate Contact Information

An alternate contact is a person in the family or close to the family we can call ONLY if we cannot reach Guardian 1 or Guardian 2.

Name

First Name

Last Name

Phone

Country

(###)

###

####

Relationship to Camper

Doctor Information

Primary Care Physician Name

First Name

Last Name

Office Phone Number

Country

(###)

###

####

Physician who manages your child's diabetes (Endocrinologist)

Name

First Name

Last Name

Office Phone Number

Country

(###)

###

####

Camper Immunization Information

Camp Freedom is required to obtain your child's immunization records. Please email these records to camp@stjda.org.

Text

Camper Health Insurance Information

Please fill out the insurance information below OR email a picture of the FRONT and BACK of your insurance card to camp@stjda.org. Copies of insurance cards are required for all campers, including non-diabetics, in the event of medical treatment or prescriptions outside of Camp Freedom.

Insurance Provider Details

Consent

The following information may be used and disclosed in the case of medical necessity

Please review the following consent statements. I/We hereby give my/our consent for my camper to attend and participate in all activities of Camp Freedom and hereby agree to hold harmless Camp Freedom and/ or its sponsors, its agents, servants or employees from any liability of whatsoever nature and injuries, sickness or other damages suffered by us or camper during his/her/their stay at Camp Freedom and by any act of omission of said organization, their agents, servants or employees. // Por la presente, doy mi consentimiento para que mi campista asista y participe en todas las actividades de Camp Freedom y por la presente acepto eximir de toda responsabilidad a Camp Freedom y/o a sus patrocinadores, agentes, sirveintes, y empleados de cualquier tipo de responsabilidad, lesiones, y enfermedad y otros daños sufridos por nosotros o campista durante su estancia en Camp Freedom y por cualquier acto de omisión de dicha organización, sus agentes, sirvientes y empleados. I/We authorize South Texas Juvenile Diabetes Association (STJDA) to use my child's photo/likeness to promote youth events, publicize the youth program, and/or fund-raise for South Texas Juvenile Diabetes Association. // Autorizo a la Asociación de Diabetes Juvenil del Sur de Texas (STJDA) a usar la foto/semejanza de mi hijo para promover eventos juveniles, divulgar el programa juvenil y/o recaudar fondos para la Asociación de Diabetes Juvenil del Sur de Texas. I/We authorize the medical staff of Camp Freedom to administer or authorize emergency medical treatment in our absence. I/We understand that every reasonable effort to notify us will be made prior to rendering treatment. // Autorizo al personal médico de Camp Freedom a administrar o autorizar tratamiento médico de emergencia en nuestra ausencia. Yo entiendo que cada esfuerzo razonable para notificarnos será hecho antes de dar tratamiento. I/We authorize urgent care treatment including, but not limited to hospitalization to the closest hospital facility. // Yo autorizo el tratamiento de atención de urgencia que incluye, entre otros, la hospitalización en el centro hospitalario más cercano. I/We understand that the protocol used to manage diabetes at home is not necessarily the protocol that will be used at Camp Freedom. // Entiendo que el protocolo utilizado para controlar la diabetes en el hogar no es necesariamente el protocolo que se utilizará en Camp Freedom. I/We authorize medical staff to make any necessary insulin dose changes during camp to ensure the safety of my child. // Autorizo al personal médico a realizar los cambios necesarios en la dosis de insulina durante el campamento para garantizar la seguridad de mi hijo. In addition, I/We authorize South Texas Juvenile Diabetes Association (STJDA) to release pictures, photographs, slides or movies for publicity or public usage. Además, autorizo a la Asociación de Diabetes Juvenil del Sur de Texas (STJDA) a publicar imágenes, fotografías, diapositivas o películas para publicidad o uso público.

Agree & Consent

I do not provide my consent

E-Signature

By typing your name in the field below and clicking “Submit,” you: 1) Acknowledge & Agree that your typed name constitutes your electronic signature, which has the same legal validity and enforceability as a handwritten signature. 2) Consent to receive and sign documents electronically in accordance with the U.S. Electronic Signatures in Global and National Commerce Act (ESIGN Act, 15 U.S.C. 7001 et seq.) and any applicable state laws such as the Uniform Electronic Transactions Act (UETA). 2) Understand that you are not required to sign electronically, and if you prefer to sign in ink (or via another method), please contact us to arrange an alternative. Confirm that you have the software and hardware necessary to view, receive, and retain electronic records, and that you have the ability to print or store these records for your own reference.

!!BEFORE STARTING THIS APPLICATION!!

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