Diabetes, Incorporated

Diabetes,
Incorporated
MEDICAL WAIVER
AND
AUTHORIZATION FOR
TREATMENT
I , the undersigned, know that camping
can involve risk of personal injury. I
agree that as a participant, it is my
responsibility to take an active role i n
understanding and accepting these
risks, conditions, and hazards for my
own safety and that of my child.
I
hereby assume all risk for loss, damage
or injury to myself, my child, and my
property from any cause whatsoever. I
acknowledge that I am responsible for
my own safety and that of my child while
participating i n the "Kamp for Kids"
retreat.
Family Diabetes
Camp
«T1D Can't Beat Me*
AUGUST 9-11, 2013
Outlaw Ranch
Custer, SD
Sponsored in cooperation witli the
Rapid City Cosmopolitan
Club
IM
M I I M M
I hereby waive, release, hold harmless,
and discharge any and all claims for
death, personal injury, or property
damage which I may have or which may
hereafter accrue to me or my child as a
result of my participation i n the "Kamp
for Kids" retreat.
I hereby discharge, i n advance, the
organizers, sponsors,
any
affiliated
organizations,
and
the
respective
volunteers, agents and employees of any
of the above from any and all liability
arising out of or connected i n any way
with my participation in this event.
I hereby authorize any staff member of
the "Kamp for Kids" retreat to provide
emergency medical treatment or seek
emergency care for myself or any
member of my family should the need
arise.
Parent/Guardian Signature
Date
INTRODUCTION
Diabetes,
Incorporated
organization
whose
is
a
purpose
2013 K A M P F O R K I D S F E E S
non-profit
>
is to provide
information and other services to people with
Youth education and family wellness are areas
of primary emphasis of Diabetes, Incorporated.
We are pleased to be able to offer this special
August 9-11, 2013. It will kick off witi
and
children
registration at 4:00PM on Friday, 8/9/1:
One
Parent/Guardian
of various
Kamp
who are dealing with the same problems and
issues, and provides them a wider support
education is
service
clubs,
on the agenda: (1) a talent show (so star
rehearsing),
canoeing, (4) night geo-caching, (5) Teer
possible.
"Extreme Hike" (bring proper shoes), (6)
A parent or a prearranged,
must accompany
welcome.
(2) horse
back
riding, (3
each
D.J/Dance, (7) D-Cathlon (Come as youi
Other family members
favorite Super Hero), (8) Outdoor Sports
Additional
family
(9) Bingo, (10) and much, much more
members may attend at a reduced
Camp will conclude on Sunday evening aftei
cost of:
supper with the raffle and awards drawings.
Ages 12-Adult
$50.00
Ages 4-11
$25.00
extremely important, so is having fun, and WE
Children under 4
DO HAVE FUN! Kamp for Kids offers a variety of
(Fee includes meals, snacks & lodging)
fun and educational activities for everyone
and pizza around the campfire at 5:30. Als(
this financial assistance has been made
are
their families the opportunity to meet others
With the
corporations, individuals and fundraising
diabetic child.
for Kids offers young people with diabetes and
diabetes
Our SUPER HERO theme camp will be hel<
K a m p for Kids FREE of c h a r g e
adult sponsor
camp for children and teens, ages 0-18+ (or
Although
attend
generosity
and the public.
networl<.
DIABETIC
attends FREE of charge.
diabetes, their families, health care professionals
high school seniors), and their parents.
All
Kamp for Kids 2013
Raffle tickets are available for fund-raising
Please contact us if you would like to have
additional raffle tickets to sell to support
Free
your participation at camp.
Registration deadline is June 30, 2013.
We will also be doing a collage of all the
Registrations will be accepted until
kids attending camp this year.
camp is full, however they may be
send a current photograph of youi
charged
$20.00.
children (Type 1 and Type 3 -siblings]
Our knowledgeable camp staff of medical
Information packets will be mailed
with your registration to be displayed at
professionals
to all registrants by 7/26/13.
camp with their name detailed on the back.
involved and participants will gain confidence in
>
their ability to deal with diabetes.
DIABETES MANAGEMENT
and enthusiastic
volunteers
will include doctors, psychologists, diabetic
educators and dieticians.
assistance
and
late
fee of
ACCOMMODATIONS
This wonderful
group of individuals will be available to
provide
a
consultation
on
diabetes management and how to cope with
the day to day problems.
>
Outlaw Ranch is located in the beautiful
southern Black Hills.
The cabins are
nestled among the beautiful pines and
offer a quiet environment in which to
relax. Meals are provided (please request
Copyright © 2000-2013 Diabetes, Incorporated
special dietary needs with registration).
Please
Scholarships are available for
guardians, & siblings (Type 3s).
Please submit a letter request with
your registration packet or by email
to d la b e t e s i n c @ q w e s t o f f ice. net.
Like us on Facebook for updateshttps://www.facebool<.com/groups/KampforKids/
AfAME
SEX
DATE OF
DIAGNOSIS
(Ml
DIABETIC
CHILD'S
BIRTH DATE
If Child, T.
SHIRT
SIZE
(Specify
AdultlChild)
CHILD
FEE
FREE
FREE
ONE LEGAL
GUARDIAN
T-Shirts are provided free to all childrenplease specify size
Add $10.00 each for additional T-Shirts ordered
REGISTRATION DEADLINE: 06/30/13
Add $20.00 late fee if mailed after 06130113
TOTAL
DUE:
(NON-REFUNDABLE
CHECK FOR $20.00 IS
REQUIRED
A T REGISTRA TION if applicable)
AMOUNT
ENCLOSED:
BALANCE
DUE AT KAMP
(TOTAL DUE LESS AMOUNT PAID AT
Can your
child's (children 'sjpicture
Are you interested
in: Taste
Cosmo Kids?
Q Yes Q No
Other:
PARENTI GUARDIAN.
ADDRESS
CITY
PHYSICIANS NAME
UTTUHJ^
TO:
be used in camp publicity?
of Caring
Diabetes
FOR
KIDS:
REGISTRATION)
Q Yes Q No
0 Yes U No
inc. Board of Directors?
Q No
0
EMAIL
STATE
ADDRESS
ZIP
PHONE
PHONE
D i a b e t e s , I n c o r p o r a t e d K a m p for K i d s
P.O. Box 9368
Rapid City, South Dakota 57709-9368
Questions? Call 605-341-1273 or email [email protected]
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