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APPLICATION

Where: Spring Hill: 90 minutes South of Indianapolis

2017 NO LIMITS DIABETES SUMMER ADVENTURE APPLICATION

*Gender:
Male Female

DUE TO THE NATURE AND EXPECTATIONS OF THE PROGRAM, APPLICANTS MUST BE 13 AND OLDER
Type 1 Type 2 Diabetes (Both type 1 and 2 accepted)

Medications taken for diabetes:

A. Oral Agents:

(Amount and time taken)
Use syringe Use Pen Pump
(Amount and time taken):

Pump: Basal rates:

(list start time and units per hour)

If correction or carb coverage vary during the day list all below:

C. Diet: Do you use

Carb counting Exchanges

Amounts of diet:

Carbs by meal:

Exchanges or total Calories:

All meals will be served buffet style. Teens are responsible for their own proper meal selections. Assistance in portion selection is provided. Teens are expected to follow Well balanced meals and proper caloric intake

D. If you take any other medications than listed above, please list type, amount and time:

The camp is accredited by the American Camping Association which requires that all medications other than insulin, glucagons and bee sting kits be kept in a locked contaiiner Insulin, syringes, testing materials and pens will be provided. Pump supplies cannot be due to all of the types used. Non-diabetes medications and pump supplies must be provided by the family.

Please list any other health conditions, allergies or developmental situations that might affect our care of your teen during his or her stay at No Limits:

Cost of the camp is $325. If you need assistance with this fee, please indicate amount requested $ and reason for request.

Reason:

Scholarship funds are limited every effort will be made to assist with part or all of request but it may not be possible. Applications requesting help should be submitted as early as possible as scholarships will be provided first come first served as long as funds are available.

Deposit of $50 is required prior to consideration of the application. All applications will be reviewed by committee so that there may be some delay in notification depending on the next date of application consideration. Applications will be considered by age and ability to participate in an active program. Due to the age group served, a higher level management is expected than by most diabetes camps. The No Limits program is very active and participation to the best ability of each teen is expected. There will be a wide choice of activities with only a limited number that are more inactive. Teens must realize that many of the activities are physically challenging and all are planned to be at high levels of activity.

All active programs carry some inherent risks. Every effort is made to insure that the experience is safe. Careful instructions will be given for all activities. It is our expectation that all participants will follow the safety procedures. No responsibility can by assumed by the camp or no limits for those who do not follow these procedures. If this becomes a significant problem, it is understood that parents will be asked to pick their teen up from camp. Safety is our greatest concern. It is understood that photographs or videos may be made during the camp to be used for promotional and/or publicity. Permission is hereby given.