Microsoft word - child registration papers, 2012 bjdasg camp.doc

MEDICARE NUMBER (and number the child is on it) HEALTHCARE OR Age at diagnosis ______ Year diagnosed ______ accompany child to camp? PARENT/CARER DETAILS SURNAME Diabetes Specialist:________________________________________ General Practitioner:_______________________________________ Diabetes Educator:________________________________________ Dietitian:________________________________________________ DONATION ENCLOSED: yes □ no □ Amount: _______________ (Payable to Bundaberg Juvenile Diabetes Action Support Group Inc.) INFORMATION ABOUT YOUR CHILD’S INSULIN NAME: __________________________ BREAKFAST: Very Fast Acting Units Fast Acting Stomach □ Legs □ Arms □ Buttocks □ Lumps? □ Stomach □ Legs □ Arms □ Buttocks □ Lumps? □ Stomach □ Legs □ Arms □ Buttocks □ Lumps? □ Stomach □ Legs □ Arms □ Buttocks □ Lumps? □ Stomach □ Legs □ Arms □ Buttocks □ Lumps? □ Medtronic □ Animas □ Cosmo □ Spirit □ Combo □ PUMPERS PLEASE FILL OUT PUMP SETTINGS Pump settings form attached □ FORM AND ATTACH TO REGISTRATION ADDITIONAL INFORMATION: Recent HbA1c result Would you like information about pumps? OTHER MEDICAL INFORMATION: NAME: _____________________________ AGE: _____________ Does your child suffer any other conditions? If yes, please specify Does your child take any medications other than insulin? If yes, please complete attached medication form. Does your child have any allergies? If yes, what to. Please specify symptoms and treatment Is your child’s immunisation up to date? Has your child recently been in contact with any contagious diseases? Does your child wet the bed? INDEMNITY FORM (YOU MUST SIGN TO ATTEND CAMP) To: Bundaberg Juvenile Diabetes Action Support Group INC., PO BOX 4571, BUNDABERG
SOUTH, Q, 4670
I/We request that you accept the application of my/our child/children to attend the camp for
children with diabetes, and in consideration of your doing so I/we agree with you (which
expression includes your officers, servants, volunteers and agents and each of them) that I/we
shall at all times hereafter well and sufficiently indemnify and keep indemnified you against all
liability whatsoever to or in respect of our/my said child/children however arising (including
arising from negligence) and against all actions, suits, proceedings, claims, demands, costs and
expenses whatsoever which may be taken or made against you or incurred or become payable by
you in respect thereof.
I/We authorise you to obtain all such medical assistance and treatment of my/our child/children
as shall seem desirable and for this purpose as my/our agent or agents to engage doctors, nursing
sisters and hospital accommodation and I/we agree to pay all doctors, nursing and hospital fees
and expenses incurred on behalf of my/our child/children to you on demand.
(This means consent for medical and diabetes care, emergency, medical, anaesthetic and surgical
care.)
CHILD’S NAMES: (Please Print)
ATTENTION PARENTS, FAMILY AND FRIENDS MORNING TEA!! A MORNING TEA will follow camp presentations on Monday 2nd April. See your letter for details. We WILL/WILL NOT be attending the MORNING TEA on MONDAY. THERE WILL BE ________ Adults & ________ Children (include camper) Diabetes Youth Camp – Consent Agreement Sharing Information I hereby give permission to the Camp Coordinators of the Bundaberg Diabetes Youth Camp run by the Bundaberg Juvenile Diabetes Action Support Group Inc. to seek relevant information from, or release relevant information to the following parties if there is a legitimate reason for doing so:- Medical practitioners and other Health Professionals Other agencies providing services to my child And only these nominated individuals:- ________________________ I understand that such information will be about my child’s safe participation in the Diabetes Camp or about his/her Diabetes management. I realise that this Consent Agreement may be shown to another party as evidence of my consent in this matter. I have been assured that all such communications shall be conducted by delegate/s of the Bundaberg Juvenile Diabetes Action Support Group Inc. in the strictest confidence, and shall at all times uphold my child’s dignity and, where applicable, that of his/her family or guardian. Photographs, Videos and the Media I give consent for photograph or video footage of my child to be taken Yes □ No □ I consent to such photos or video footage being used in the media (This includes web based media) I consent to my child being interviewed by the media Yes □ No □ Swimming I consent to my child swimming at the local beach, river and/or pool (supervised) Yes □ No □ Description of my child’s ability to swim ___________________________________________ CAMPER’S PARENT/GUARDIAN This Consent Agreement remains current for the duration of the What type of diet does your child follow? □ Healthy eating plan according to Food pyramid □ Glycaemic Index □ 15gm carbohydrate exchange □ Counting carbohydrates in grams Does your child have any food allergies? If yes, please specify Please complete the following menu with what your child would eat on a regular day Breakfast
Morning Tea
Afternoon Tea

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