2022 Camper Registration Form Step 1 of 7 14% Camp Banting 2022 Online Registration FormsThe following pages contain the online registration forms for camper and medical information that we need for camp. For 2022, we've done our best to streamline our forms, removing some information and consolidating everything into one place. Please note that if you're registering more than one camper that you'll need to fill out separate versions of this form. Our testing indicates that it can take ~30-60 minutes to complete the forms. If you have any issues, please reach out to Andrew Leonard, at [email protected] or direct by phone at (613) 690-6067.To complete the online forms, you'll need the following information about your camper and family. It is not possible to save the form and continue later, so we recommend using our handy checklist here to make sure you're prepared before clicking "next"! Contact information for all parents/guardians Camper's t-shirt size Cabinmate requests (if any) Health card / insurance number and expiry Family doctor's name Diabetes specialist/doctor's name Immunization information (exact dates not required) Allergy information (if any) Dietary restrictions (if any) Medication information (if any) Date of T1D diagnosis Pump model (if using pump) CGM model (if using CGM) Please make sure you have all the above information before clicking "next"!HiddenName First Last HiddenEmail HiddenUser Login HiddenUser ID Camper's Name(Required) First Middle Last Camper's Nickname or Preferred Name First Camper's Birthdate(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Camper's Gender(Required) Male Female Other Parent & Guardian InformationParent / Guardian #1 Name(Required) Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Are you a legal guardian of this camper?(Required) Yes No What is your relationship to this camper?(Required) Mother Father Other Home Phone(Required)Cell PhoneCell phone same as home? Yes No Work PhonePrimary Email Address(Required) Mailing Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Please enter an address where you can receive mail. NOTE: if you are an agency professional filling this form out on behalf of the family, please enter the primary mailing address for the family.If applicable - Parent / Guardian #2 Name Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Is parent / guardian #2 a legal guardian of this camper? Yes No What is parent / guardian #2's relationship to this camper? Mother Father Other Parent / Guardian #2's Home PhoneParent / Guardian #2's Cell PhoneParent / Guardian #2's Work PhoneDo both parents / guardians live together with this camper? Yes No Which parent/guardian has legal custody of this camper? Parent / Guardian #1 Parent / Guardian #2 Both / Shared Custody Are there any concerns or family situations that the camp staff should be aware of?(Required) Yes No This can include strained family dynamics, adults that are to have no contact with the child for legal reasons or otherwise, or any other concerns/situations of this nature.Please let us know in details what these concerns or situations are. Camper General InformationChild's T-shirt Size(Required)Youth SYouth MYouth LYouth XLAdult SAdult MAdult LAdult XLAdult XXLHas your child been away from home before?(Required) Yes No Where have they been away and for how long?Has your child attended a diabetes camp other than Camp Banting?(Required) Yes No Has your child been a camper at Camp Banting? Yes No Is your child eager to attend camp?(Required) Yes, so excited! Yes. somewhat. No, we're encouraging him/her. Doesn't want to go at all, but we're hoping it will be good for him/her. Not every child wants to go to camp. Some are registered on a doctor's advice, or simply just in the best interest of the child. This question allows the medical team and your child's counsellor to calibrate to the level of excitement your child has going in. Don't be afraid to answer honestly!Are there other campers your child would like to be placed with in a cabin group?(Required) Yes No Please note that that cabinmate requests must be close in age to your child (generally within a year or two). We'll do our best but cannot guarantee that requests will be accommodated!Cabinmate Request #1 First Last Cabinmate Request #2 First Last Does your child have and fears (for example: dark, water, heights)?(Required) Yes No Please let us know what these fears are...This information will be passed along to your child's counsellors so they can be sensitive to these fears.Can your child swim?(Required) Absolutely, the water is like a second home. Yes, and is comfortable in deep water. Learning, but isn't comfortable in deep water. No, not at all. What activities, clubs, teams, or hobbies is your child involved in at home?(Required)Are there any activities your child should *NOT* do at camp?(Required) Yes... No, it's all good! What activites should they not participate in and why?Does your child know and spend time with other children who live with diabetes?(Required) Yes No Not sure Over this past school year, how has your camper been feeling about living with diabetes?(Required)Is there anything else you'd like your child's counsellors and medical team to know about your child's personality and time at camp?We're looking for Parent Committee volunteers!Our families are the lifeline of Camp Banting, and we’re looking to you to help us grow! We are always looking for ways to form connections and garner financial support from the local community. In an effort to keep our fees down and our community strong, we are looking to build a Parent Committee. If you’re interested in receiving more information about this, please select which statement below best describes you. I am interested in receiving further information about the Parent Committee, and opportunities to help promote and fundraise for Camp Banting. I have experience in fundraising and promotions. I am not interested in joining the Parent Committee at this time, but would be willing to provide you with ideas of how to grow. I'm full up right now, but thanks for asking! Camper General Medical InformationIs this child covered by provincial health care in Canada?(Required) Yes No Attach a copy of child's medical insurance coverage(Required)Accepted file types: jpg, png, pdf, Max. file size: 20 MB.If your camper is not covered by provincial health insurance, you must attach a copy of their medical insurance coverage. Children without provincial health insurance may be billed for the routine medical care they receive while at camp. Allowed file formats are JPG, PNG, or PDF.Child's Health Card Number(Required) Province of Health Care Coverage(Required) AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Date of Expiry on Health Card(Required) MM slash DD slash YYYY Family Doctor's Name(Required) First Last Family Doctor's Phone NumberDiabetes Specialist's Name(Required) First Last Diabetes Specialist's Phone NumberWhat diabetes clinic sees your camper (for example, CHEO or Kingston)(Required) How many COVID vaccine shots has your camper received?(Required)The situation with COVID-19 policies as they relate to overnight summer camps is fluid. However, please note that we anticipate a full course of COVID vaccination being a requirement for children to attend camp this summer. One dose Two doses Two doses plus booster Not yet vaccinated but planning to No plans to vaccinate for COVID Has your camper received a full or partial course of immunizations as recommended by Ontario school and public health guidelines?(Required)This includes immunizations for diseases such as hepatitis B, tetanus, diphtheria, pertussis (whooping cough), etc. Up to date as per school/public health recommendations Partially immunized (please specify) My child has not been immunized I'm not sure Please list, to the best of your knowledge, your child's immunization history.(Required)Does your child have any allergies to medications?(Required) Yes No Medication Allergy Information(Required)Allergy caused by:Description of reaction and symptoms:Description of treatment: Add RemoveUse the "+" to add rows.Does your child have any environmental allergies?(Required) Yes No Environmental Allergy Information(Required)Allergy caused by:Description of reaction and symptoms:Description of treatment: Add RemoveUse the "+" to add rows.Does your child have Celiac Disease?*(Required) Yes No Does your child have any allergies to food (other than celiac listed above)?(Required) Yes No Food Allergy Information(Required)Allergy caused by:Description of reaction and symptoms:Description of treatment: Add RemoveUse the "+" to add rows.Does your child carry an EpiPen or similar device?(Required) Yes No For what allergy does your child carry this device for?(Required) Does your camper have meat restrictions in their diet?(Required) Yes No Meat Restrictions(Required) Vegetarian (no meat / animal protein)) Vegan (no animal products at all) No fish No poultry No red meat No pork and pork products Does your camper have milk/dairy restrictions in their diet?(Required) Yes No Milk/Dairy Restrictions(Required) Intolerance who can have milk in recipes Intolerance who cannot have milk in recipes Drinks lactose free milk as an alternative Drinks soy beverages as an alternative Please note that we offer lactose free and soy beverages as dairy alternatives. Nut milks such as almond and coconut are difficult to provide at camp owing to other nut-based allergies in our camper population.Does your camper have other dietary restrictions?(Required) Yes No Please detail the 'other' dietary restrictions your child has.(Required)Has your camper experienced any of the following? Hypothyroidism Hyperthyroidism High blood pressure High cholesterol Kidney problems Asthma Seizure disorder Other neurologic condition Heart or lung problems Stomach/gastrointestinal problems Muscle or joint problems Physical disability Other Please specify the details of this experience, including diagnosis dates and treatment.(Required)Is your camper currently taking medication (other than insulin)?(Required) Yes No What medications and doses is your camper currently taking?(Required)Medication nameMedication is forMedication dose details Add RemoveUse the "+" button to add more rows.Has your camper recently experienced... (check all that apply)(Required) Major surgery Recent hospitalization None of the above Please explain the details of that experience(Required)Has your camper experienced any mental health, behavioural, developmental, or learning issues or disorders (diagnosed or undiagnosed)?(Required) Yes No Please check all that apply ADD / ADHD Oppositional Defiant Disorder Anxiety Depression Bipolar Disorder Self-harm Behaviour Suicidal Ideation Eating Disorder / Body Dysmorphic Autism Spectrum Disorder Schizophrenia Personality Disorder Developmental Impairment Learning Impairment Other Please describe the disorder, issues, or impairment more fully. Include current treatment plan, triggers, support required, etc.Does your camper work with a mental health or developmental care practitioner on this issue? Yes No Name of practitioner(Required) First Last Practitioner's Phone Number(Required)Type of Practitioner(Required) Psychiatrist Psychologist / Psychotherapist Physican / Medical Doctor Occupational Therapist Behavioural Specialist Other Does your child live with any other medical conditions, diseases, or disorders that haven't yet been covered in this form, either current or recent?(Required) Yes No Please describe these issues in detail, including type, severity, treatment, and support required.(Required)Is there anything else medical or health related (other than diabetes) that you would like our team to know about your child? Diabetes InformationType of Diabetes(Required) Type 1 Type 2 Other Please explain(Required) Year of Diagnosis(Required)2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001Month of Diagnosis(Required)01-Jan02-Feb03-Mar04-Apr05-May06-Jun07-Jul08-Aug09-Sep10-Oct11-Nov12-DecCamper's insulin is delivered by...(Required) Pump Injections How many time points in the day do you give insulin?(Required) 2 3 4 or more Is your camper planned or scheduled to start on a pump before camp?(Required) Yes No Pump Type Medtronic 630G Medtronic 670G Medtronic 770G Omnipod t:slim with Basal-IQ t:slim with Control-IQ Auto mode enabled?(Required) Yes No Unsure Infusion Set Type(Required) Brand and/or modelDo you have plans to change or upgrade your camper's pump model before camp?(Required) Yes No What pump are you planning to change or upgrade to?(Required) Medtronic 630G Medtronic 670G Medtronic 770G Omnipod t:slim with Basal-IQ t:slim with Control-IQ Unsure / don't know To check blood sugar, what does your child use?(Required) Continuous Glucose Monitor (CGM) or Freestyle Libre Fingerstick blood checks only Will you be sending the child's CGM to camp?(Required) Yes No Unsure What model of CGM does your child use?(Required) Freestyle Libre Guardian (Medtronic) Dexcom Other Would you like to try a Continuous Glucose Monitor (CGM) at camp?(Required) Yes No Maybe We will have samples of Dexcom and Freestyle Libre2 at camp that are free for your camper to try. This will give you a chance to see if you like it and means that you will not need to do fingersticks before each meal and snack.Do you have a smart device that you can provide your camper with?(Required) I have access to a device for my camper I do not have access to a device and will need a reader Dexcom CGMs require a smart device (iOS/Android) to pair with. The device does not require cell service or data, only Bluetooth. Camp CGM Devices Policy(Required)Camp Banting allows the use of continuous glucose monitors (CGM) at camp. We believe that the methods used to manage diabetes at home should be mirrored as close as possible to the methods used at camp. Most CGM units connect to a control device, including iOS and Android devices. As a result, many CGMs are monitored by phones and iPods. We allow campers to use these control devices at camp under the following conditions. 1) The control device is recommended to remain with the camper's counsellor or activity leader unless being used by the camper. 2) Control devices such as smartphones and iPods will be put into airplane mode with Bluetooth or WiFi activated as required to connect to the monitor. We do this to ensure that screens at camp are as limited as possible to diabetes related activity. 3) Devices such as smartphones and iPods will not and cannot be used to text or communicate with, or be monitored by, parents/guardians for the duration of the time that children are onsite at the Dunrobin facility. 4) Camp Banting and the YMCA-YWCA of the National Capital Region are not responsible for the loss or theft or damage of CGM control devices, including but not limited to, smartphones or iPods. Please sign or initial in the space below to certify that you understand and accept this policy, if you choose to send your camper's CGM to camp.Your Name(Required) First Last Do you have any other comments that would be helpful for the camp medical team about your camper's diabetes management?I certify that all the information I have provided about my camper on these form pages is accurate and complete.Please sign in the space provided above to acknowledge that you have completely and accurately detailed your camper's information.Your Name First Last Waivers and ReleasesBelow are the waivers and media releases used by Camp Banting. Please read, choose your agreement options, and then sign in the space provided. Consent, Liability, and Waiver(Required) I agree to the waiver and consent to participate release for Camp Banting.I, on my own behalf and in my capacity as the parent or guardian of my registered camper at Camp Banting (collectively the Applicant Family), and in consideration of the recreational and educational services provided by Camp Banting agree as follows: 1. I hereby release and discharge Camp Banting, their respective agents and employees from all manner of action, causes of action, claims or demands our Applicant Family may have, arising from or related to our attendance at camp notwithstanding that any such loss, injury or damage may have arisen by reason of the negligence of the Camp Banting, its servants, agents or employees. 2. I agree to indemnify Camp Banting, its services, agents or employee, from any claims or demands made against Camp Banting in respect to any loss or damage which they may suffer or become legally obligated to pay as a result of, or arising from the attendance of our Applicant Family at camp. 3. I consent to the administration of medical treatments on behalf of the children as is determined to be necessary by Camp Banting, its servants, agents or employees, in their sole discretion, for his/her health by the camp. 4. I certify that all information provided in registration forms I complete for the Camp Banting program is true to the best of my knowledge at the time of completing these forms. 5. I agree to review the Behaviours Expectations & Policies and I understand that should our Applicant family breach any of the expected behaviours, they could be expected to leave the camp program immediately. If this instance occurs, no refund of fees will be made available and I will be responsible for arranging our transportation from camp and the associated costs. 6. I acknowledge that we are aware that the Camp Banting program provides risk-taking and potentially hazardous outdoor pursuit programs, which could include, but are not limited to boating, swimming, hikes, games, or other activities that involve physical activity and the possibility of injury resulting from such activity. I acknowledge that the camp facility may contain physical hazards that may result in injury or death to persons or damage to property on or at the facility. 7. I acknowledge that it is the policy of Camp Banting to take all reasonable precautions to ensure children and staff safety with respect to such activities and to provide a safe environment. 8. On behalf of the Applicant Family, I freely consent to all such risks and fully assume all responsibility for the possibility of personal injury, death, disability, property damage or loss resulting thereof, howsoever caused, with the sole exception being gross negligence on the part of Camp Banting, their staff, their members, agents, employees and directors. 9. In particular I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my Child may be exposed to or infected by COVID-19 by participating in the Camp and that such exposure or infection may result in person injury, illness, permanent disability or death. I further waive and release any and all claims that our Applicant Family have or may have in the future, against Camp Banting as a result of the participation at a Camp Banting Program. This consent shall be effective and binding on our Applicant Family, heirs, next of kin, executors or administrators. I have read and understood this consent and I am aware that by signing it I am waiving certain legal rights which I, the applicant and our heirs, next of kin, executors or administrators may have.Media Consent I agree to the media consent.During the camp program, there may be pictures, films, video and other media relating to our Applicant family. As well, promotional materials involving various media may include my child. On behalf of our Applicant family, I hereby agree that Camp Banting may use and publish any of the foregoing with respect to our Applicant family, so long as no information identifying our Applicant family is included with any such media, and I hereby also specifically agree to the terms of the release as follows. I hereby consent and agree that Camp Banting, its successors, administrators or assigns (hereinafter referred to collectively as “Camp Banting”) have the right to publish my/our story, comments and/or photograph, film and/or video of our Applicant Family (collectively the “Material”) for use in Camp Banting’s campaigns, promotions, advertisements and in any other way that furthers Camp Banting’s objectives. I understand that the Material may be published in any and every form of media in both domestic and foreign markets and may be included in whole or in part, in colour or in black and white. I hereby release and discharge Camp Banting and all persons acting under Camp Banting’s permission or authority or those for whom Camp Banting is acting from and against any liability resulting from the foregoing use of the Material or from any distortion, blurring, alteration, and/or use in composite form, whether the same is intentional or otherwise, that may occur in the taking of, processing, reproduction, or presentation of the Material. I hereby waive my right to inspect and/or approve the finished story, comments and/or photograph, film or video in whatever media the Material may be used or the eventual use to which the Material may be applied. As part of the release, I hereby assign to Camp Banting any copyright that I may have in the Material, and also specifically waive any moral rights that I may have with respect to the Material. I have read the foregoing release and warrant that I fully understand the contents thereof. It is understood that my/our identity may be used by Camp Banting when publishing/releasing information as noted in this document.SignaturePlease sign in this box to acknowledge you have read Camp Banting's releases and waivers.Your Name First Last Today's DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920