| Express Check In - Online Medical Survey | Criteria for Express Check-In * Attended a 3-week session in 2018 * Completed and turned in all enrollment paperwork * Completed this online survey * Available for follow-up medical phone call When your paperwork and this survey is complete, the Camp Sweeney medical staff will follow up with a personal phone call. Please make sure you will be available at the phone number you provide in this survey. CALL TIMES: Med Staff will be calling from now through 1PM on Saturday before opening day. | ||||||
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| Camper Name | Eliyah Morales | ||||||
| Camper Birthdate MM/DD/YYYY | 01/29/2004 | ||||||
| Session Camper is Attending |
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| Primary Guardian | This is the person we will be contacting for follow-up. | ||||||
| Primary Guardian Name | Kassandra Reyes | ||||||
| Primary Guardian Phone | (254) 548-6337 | ||||||
| Phone Type | Cell | ||||||
| Primary Guardian Email | Email hidden; Javascript is required. | ||||||
| Primary Guardian Relationship to Camper | Mother | ||||||
| Alternate Guardian | In case we cannot reach the primary guardian. | ||||||
| Alternate Guardian Name | Denise Pina | ||||||
| Alternate Guardian Phone | (254) 716-1012 | ||||||
| Phone Type | Cell | ||||||
| Alternate Guardian Email | Email hidden; Javascript is required. | ||||||
| Alternate Guardian Relationship to Camper | Grandparent | ||||||
| Medication and General Health | |||||||
| Has your camper been ill or prescribed any antibiotics within last 60 days? | No recent illnesses | ||||||
| Does your camper have any medical conditions other than diabetes? | Yes camper other medical conditions | ||||||
| Please explain the other medical conditions your child has. | acid reflux | ||||||
| Is your camper currently taking any over-the-counter or prescription medication (not including insulin)? | Yes - list below | ||||||
| Tell us about your medications |
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| Does your camper have any DRUG ALLERGIES? | No drug allergies | ||||||
| Meals | |||||||
| Meal Plan link | Please make sure you choose the correct meal plan for your child. We will not be able to change it during EXPRESS registration. Click the button below to see more information about specific meal plans. Meal Plans | ||||||
| Select a Meal Plan | 2300 kCal (72g/meal) | ||||||
| Are you open to the Medical Staff adjusting your camper's meal plan as needed over the summer? | Yes | ||||||
| Does your child want Milk at meal times? Check all that apply. |
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| Vegetable Portion Size? | Small Vegetable | ||||||
| Does your camper have any FOOD ALLERGIES or INTOLERANCES? | No food allergies or intolerances | ||||||
| Diabetes | |||||||
| Does this camper have diabetes? | Yes | ||||||
| What year was your camper diagnosed? | 2011 | ||||||
| When was the date of your camper's most recent HbA1c? MM/DD/YYYY | 05/13/2019 | ||||||
| What was your camper's most recent HbA1c? | 11 | ||||||
| Insulin | |||||||
| What type(s) of insulin will your camper use this summer at Camp? |
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| What is your camper's insulin to carb ratio for BREAKFAST? | 1V:10 | ||||||
| What is your camper's insulin to carb ratio for LUNCH? | 1V:10 | ||||||
| What is your camper's insulin to carb ratio for DINNER? | 1V:10 | ||||||
| What is your camper's insulin to carb ratio for BEDTIME? | 1V:15 | ||||||
| Would you like your camper to receive insulin for a 15g afternoon snack? | No | ||||||
| Correction Scales | |||||||
| How much insulin do you give when correcting for highs during BREAKFAST/MORNING? | 2 units150-200(50) 3 units 200-250 4 units 250-300 5 units 300-350 ect.. | ||||||
| How much insulin do you give when correcting for highs during LUNCH/AFTERNOON? | Same as above | ||||||
| How much insulin do you give when correcting for highs during DINNER/EVENING? | Same as above | ||||||
| How much insulin do you give when correcting for highs during BEDTIME/OVERNIGHT? | 0 | ||||||
| Insulin Delivery | |||||||
| Will your camper use a pump at Camp? | No | ||||||
| CGM | |||||||
| Will your camper use a CGM at Camp? | Yes | ||||||
| Which CGM will be used? | Freestyle Libre | ||||||
| When will be the last time the CGM site is changed before arriving at Camp? | 07/05/2019 | ||||||
| Call |
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| Completed |
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| Entry ID | 37717 | ||||||
| Entry Date | July 19, 2019 |
Express Check-In 2019
2024 Summer - Third Session
Starts In