Teen Weekend Application

Camper Name*
First Middle Last
Name the CAMPER prefers to be called*
This name will be on all the camper's paperwork, bedtag, and name button, and how the camper will be addressed while at camp.
Camper Birthdate MM/DD/YYYY*
MM slash DD slash YYYY
Camper Sex*
Required for cabin assignment.
- Male
- Female
Current Grade in School*
Camper Address*
Street Address City State / Province / Region ZIP / Postal Code
Has the camper attended Camp Sweeney before*
Check all that apply.
- Yes - camper attended Teen Weekend
- Yes - camper attended summer session
- Yes - camper attended another Sweeney event
- No - camper has never attended Camp Sweeney
T-Shirt Size*
Be sure of your size because we will pre-order based on your selection
CAMPER's Email
If the camper does not have an email, leave blank.
Guardian Info
Guardian 1 Name*
First Last
Guardian 1 Relationship to Camper*
Does guardian 1 live at the same address as the camper?*
- Yes address is the same as camper
- No address is different
Guardian 1 Address*
Street Address City State / Province / Region ZIP / Postal Code
Guardian 1 Phone*
Phone Type*
- Cell
- Home
- Work
Guardian 1 Email*
Do you have Guardian 2 info to enter?*
- Yes - I have another guardian to enter who lives with us
- Yes - I have another guardian to enter who does NOT live with us
- No - I am a single parent
Guardian 2 Name*
First Last
Guardian 2 Relationship to Camper*
Guardian 2 Address*
Street Address City State / Province / Region ZIP / Postal Code
Guardian 2 Phone*
Phone Type*
- Cell
- Home
- Work
Guardian 2 Email*
Alternate Contact
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.
Alternate Contact Name*
First Last
Alternate Contact Relationship to Camper*
Alternate Contact Phone*
Medication and General Health
Is your camper currently taking any over-the-counter or prescription medication (not including insulin)?*
You should bring enough medication for the 3-day weekend. All meds should be in its ORIGINAL CONTAINER. We will not be able to accept baggies or any other container.
- No medications
- Yes - list below
Tell us about your medications*
Please list the name of your medication and its purpose. You will be asked about dosage and frequency during express check-in. Click the + to add additional medications.
Med Name Purpose Dosage Frequency (how often) Duration (end date, if any)
Does your camper have any DRUG ALLERGIES?*
- No drug allergies
- Yes - explain below
Please explain drug allergy and reaction:*
Has your camper recently been ill or been prescribed any antibiotics? (within last 60 days)*
- No recent illnesses
- Yes - explain below
Please explain recent illnesses:*
Does your camper have any additional medical conditions (other than diabetes)?*
Diabetes Info
Diabetes Status*
- Type 1 Diabetes
- Type 2 Diabetes
- At Risk of Developing Diabetes
What year was your camper diagnosed?*
What was your camper's most recent HbA1c?*
When was the date of your camper's most recent HbA1c? MM/DD/YYYY*
MM slash DD slash YYYY
MEAL PLANS
Click the button below to see more information about specific meal plans.
Meal Plans
Meal Plan*
Please choose the meal plan below so we will know how much to feed your child. We serve 3 meals plus 2 snacks a day. Your child will be able to change their meal plan during the weekend as desired.
Does your child want Milk at each meal? Check all that apply.*
- Breakfast
- Lunch
- Supper
- No milk at any meal
Vegetable Portion Size?*
- Small Vegetable
- Large Vegetable
Does your camper have any FOOD ALLERGIES or INTOLERANCES?*
- No food allergies or intolerances
- Yes - explain below
Please explain food allergy and reaction:*
What insulin(s) does your child use?*
Check all that apply.
- V - Novolog
- H - Humalog
- A - Apidra
- G - Lantus
- D - Levimir
- J - Toujeo
- T - Tresiba
- S - Basaglar
- F - Fiasp
INSULIN / MEAL PLAN CARB RATIOS
Please use the following Insulin Brand abbreviations when listing ratio dosages: H-Humalog, V-Novolog, A-Apidra, G-Lantus, D-Levemir, J-Toujea, t-Tresiba, S-Basaglar, F-Fiasp

What is your camper's insulin to carb ratio for the following? For example, 1 unit of Novolog insulin for every 10 grams of carbs = 1V:10
BREAKFAST insulin to carb ratio*
LUNCH insulin to carb ratio*
SNACK (15g carb) insulin to carb ratio*
DINNER insulin to carb ratio*
BEDTIME insulin to carb ratio*
LONG ACTING/BASAL insulin type and time administered*
CORRECTION SCALES
How much insulin do you give when correcting for highs during the following times? For example, 1 unit for every 50 over 150.
Breakfast / Morning correction scale*
Lunch / Afternoon correction scale*
Dinner / Evening correction scale*
Bedtime / Overnight correction scale*
PUMPS AND CGMs
Will your camper use a pump at Camp?*
- Yes
- No
What is your pump Manufacturer & Model?*
What is your pump serial number?*
How often does your camper change pump site?*
- 2 days
- 3 days
When will be the last time the pump site is changed before arriving at Camp?*
MM slash DD slash YYYY
Basal Rate
List the time range followed by the rate of insulin delivery. For example: from Midnight to 3AM : 0.5 units/hr.
click the plus sign to add additional basal rates
From (time) To (time) Units / Hour
Will your camper use a CGM at Camp?*
- Yes
- No
What is your CGM's Manufacturer & Model?*
When will be the last time the CGM site is changed before arriving at Camp?*
MM slash DD slash YYYY
Other information
INDEMNITY & RELEASE Please read carefully and SIGN below
I, the Parent/Guardian, on behalf of my minor child, as listed above, understand that use of the Southwestern Diabetic Foundation and/or Camp Sweeney facilities and participation in facility programs and events creates a risk of injury and therefore expressly consent to and assume all risks associated with use of the Southwestern Diabetic Foundation and/or Camp Sweeney facilities and participation in their programs and events, even those which are not specifically foreseeable, and release, indemnify, defend, and hold harmless Southwestern Diabetic Foundation, Camp Sweeney and their directors, officers, employees, and agents (the “Released Parties”), from any loss, liability, claim, action, or suit (“Claim”) arising or alleged to arise from (A) bodily injury or personal injury suffered by any party on the Southwestern Diabetic Foundation and/or Camp Sweeney facilities, (B) bodily injury or personal injury caused by a participant in facility programs and events (including off-site trips) and/or (C) property damage or loss suffered in connection with, or as a result of, my or my minor child’s use of Southwestern Diabetic Foundation and/or Camp Sweeney facilities or participation in their programs and events (including off-site trips), regardless of whether such claims and actions are founded in whole or in part upon alleged negligence of the Indemnified Parties. I specifically and explicitly release, indemnify and hold harmless the Released Parties (defined above) from all liability, claims, demands, actions or rights of action, or damages of any kind including but not limited to those arising out of or relating to any one or more of the Released Parties’ own sole, contributory and/or comparative negligence. I knowingly and voluntarily release, indemnify and hold harmless the Released Parties from any such claims. I have read and understand the above waiver. This Indemnity and Release is made and is performable in Cooke County, Texas. I agree that exclusive venue for all claims arising from or related to this agreement, including claims for personal injury, lies in Cooke County, Texas.

PARTICIPATION: I, the Parent/Guardian, give permission for my child to participate in all of the Camp Sweeney program activities on or off the Camp Sweeney property.

VIDEO/PHOTOS: Many pictures will be taken of all the children who attend Camp Sweeney. In addition, some video, live and recorded internet broadcasts and interviews will be taken during this session. I give the Southwestern Diabetic Foundation, Inc. permission to use the pictures, interviews, live and recorded internet broadcasts, internet pictures and videotapes of our child in any of its publicity campaigns and/or websites.

TREATMENT: I authorize the medical staff at Camp Sweeney or Southwestern Diabetic Foundation to administer or authorize routine and emergency medical treatment in my absence. I understand that every reasonable effort to notify me will be made prior to rendering emergency treatment. I understand that if any medical expenses occur during the course of camp including x-rays, blood tests, medications, and/or emergency room visits, the camper’s guardians will assume financial responsibility for expenses not covered by the camper’s insurance. In addition, both the camper and the camper’s guardian agree for the release of any medical information acquired by Southwestern Diabetic Foundation and/or Camp Sweeney to be released to the camper’s referring physician.

BEHAVIORAL RULES/PROCEDURES: The camper and the camper’s guardian agree that the camper will abide by the behavioral rules and procedures set forth by Camp Sweeney for the safety of all campers and staff.

I, the Parent/Guardian, certify that the information provided in this application is true and correct and authorize investigation of these facts by any authorized representative of Camp Sweeney.

I have read and agree to all the above releases and authorizations with regards to the camper’s stay at Camp Sweeney.
Agreement*
I have read and agree to the above releases and authorizations with regards to the camper's stay at Camp Sweeney.
Guardian, please type your full name to agree to the above terms*
Today's Date*
MM slash DD slash YYYY

Med Name	Purpose	Dosage	Frequency (how often)	Duration (end date, if any)

From (time)	To (time)	Units / Hour

Teen Weekend Application

Guardian Info

Alternate Contact

Medication and General Health

Diabetes Info

MEAL PLANS

INSULIN / MEAL PLAN CARB RATIOS

CORRECTION SCALES

PUMPS AND CGMs

INDEMNITY & RELEASE Please read carefully and SIGN below