Diabetes Camp Care Plan Form
Use this form to share the camper’s diabetes care needs, contact details, supplies, meal and activity notes, and emergency instructions for camp staff.
Camper Information
Camper Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Gender / Pronouns
Girl/Woman
Boy/Man
Non-binary
Prefer not to say
Prefer to self-describe
Guardian and Emergency Contacts
Primary Parent/Guardian Name
*
First Name
Middle Name
Last Name
Relationship to Camper
*
Please Select
Parent
Guardian
Step-Parent
Grandparent
Foster Parent
Other
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Note
Emergency Contact Name
First Name
Middle Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Diabetes Care Details
Diabetes Type
*
Type 1
Type 2
Other
Usual Glucose Monitoring Method
*
Please Select
Fingerstick
Continuous Glucose Monitor (CGM)
Both
Other
Target Glucose Range
Current Diabetes Management Routine
*
Insulin injections
Insulin pump
Oral medication
Diet and activity only
Other
Care Routine, Timing Notes, and Camp Assistance Needs
Meals, Snacks, and Activity Notes
Meal and snack timing preferences
Regular camp schedule
Early snack
Late snack
Extra snack before activity
Bedtime snack
Other
Carbohydrate counting support needed
*
Yes
No
Unsure
Food restrictions or allergies relevant to diabetes care
Special instructions for sports, swimming, hiking, overnight schedules, or other activities
Supplies, Medications, and Emergency Instructions
Supplies Camper Will Bring or Needs Provided
*
Medication Administration Instructions
*
Low Blood Sugar Emergency Steps
*
High Blood Sugar and Ketone Emergency Steps
*
Storage and Handling Notes
Submit
Should be Empty: