| Big
Shots Camp Registration
|
| Part I |
| Camper's First Name |
|
| Camper's Last
Name |
|
| Camper's Birthdate (MM/DD/YYYY) |
|
| Age as of June 22, 2008 |
|
| Grade Fall '08 |
|
| School Attending Fall '08 |
|
| Camper's Street |
|
| Camper's City |
|
| Camper's State |
|
| Camper's Zip
Code (5
digits) |
|
| Primary Contact for Registration (Parent/Guardian) |
|
Primary Contact's Home
Phone
(with
area code) |
|
Primary Contact's Work Phone
(with
area code) |
|
Primary Contact's Cell
Phone
(with area code) |
|
| Primary Contact's E-mail address |
|
| Medical
Forms : Your child must have had a complete
physical since June 22, 2006. If they have not,
please schedule right away! Forms for diabetes care should
be completed by you and signed by your child’s diabetes
Dr. closer to camp time in order to have current insulin
doses. Do NOT wait until the last minute!! |
| Part II |
| Camper has Diabetes |
Yes
No |
| If Yes, skip the
next question and complete the rest of Part II, otherwise
answer the next question and skip to Part III |
| Camper you will be attending camp
with |
|
| Date of Diagnosis
(MM/YY) |
|
| Insulin Names |
|
| Insulin Pumps Used |
|
| Insulin Pen |
|
| Blood Glucose
Meter Used |
|
| Previous Camp Attendance |
|
| Physician for Diabetes Care |
|
| M.D. / D.O. |
M.D.
D.O. |
| Physician
Phone (with area code) |
|
| Physician
Fax (with area code) |
|
| Physician
Address |
|
| Healthcare Insurance
Provider |
|
| Group Employer |
|
| DYS has my permission to bill the above insurance company for my child's camp fees. |
Yes No |
| Part III |
| Yes, I will be
printing and downloading all forms directly from the
website (preferred) |
|
| No, please mail me
all the forms right away |
|
Part
IV
Fees: $425 per child, discounted to $400 if paid before
June 1, 2008 . Please make checks payable to
Diabetes Youth Services or complete this form and make
payment(s) online at www.dys4kids.org . Camp
Scholarships available for those with diabetes with demonstrated
financial need. |
Payment Amount (no
$ sign - 0 for none)
(Note - if you enter an amount to the right,
you will automatically be redirected to the PayPal® site
to complete the payment upon submission of this form.) |
|
Camp Currency (no $ sign)
(Will be deducted from camp fee upon Camp Currency verification.) |
|
| Scholarship provided
by organization other than DYS that I have contacted locally
(Lions, Masons, etc.) Enter Organization providing scholarship
to the right: |
|
Further financial
support needed; please send me the Reduced Fee Application
before June 2 by (choose one): |
|
|
|