1. automotive and vehicles
2. campers and rvs

Dear Parent,
We are so excited your child will be joining us this summer in Noblesville, IN! You are
almost finished with registration. We must receive the health form, located in this
packet, filled out by the child’s health care provider before your child’s registration is
complete.
If you checked the box for financial aid or assistance, please complete the summer
food service form along with the corresponding financial request form(s) (located in
this packet.)
If you have chosen to pay by check or an amount other than $500 by credit card,
please complete the payment form. Any questions, please contact Jenna Holt at 317750-9310.
Please mail all completed forms to DYFI, 817 South Tibbs Avenue, Indianapolis, IN
46241 or scan and email to [email protected]. Forms can be faxed to 317-2434488 Attn: DYFI.
Additionally, you will find information about what to pack, check in, and directions to
camp in this packet. New this year: if your child is on a pump, we ask that you bring a
current (no greater than 24 hours prior to camp) printed summary of your child's
insulin pump settings from the insulin pump software. If you do not have the ability to
print the summary than an insulin pump nurse can retrieve the information as part of
the check-in process.
We are looking forward to an exciting summer! If you have any questions or concerns,
please do not hesitate to contact me at anytime!
Sincerely,
Jenna Holt
Executive Director
[email protected]
317-750-9310
Registration Packet 2014 Camp Until A Cure
Table of Contents
Health Form (To be Completed by Child’s Health Care Provider)………………………………………Page 3
Summer Food Service (If Applicable)………………………………………………...…………………...Page 5
Financial Aid Form……………………………………………………………………………..………….Page 7
Campership Application…………………………………………………………………………………...Page 8
Payment Form…………………………………………………………………………….…………..……Page 9
Camper Packing Guide……………………………………………………………...……………………Page 10
Check-In Check-Out Info………………………………………………………………...………………Page 11
Day Camp Check-In Check-Out Info…………………………………………………………………….Page 12
Directions to Camp Until A Cure………………………………………………………………………...Page 13
2
Camper _____________ ______________ Birth date ______ Sex__ Session(s)________
Last Name
First Name
Health Form
(Completed By Health Care Provider)
Last Physical Exam:
Date _____/______/_________
Child’s Weight:_____________cm/in
Height:____________kg/lb
Physical Exam Normal for Child’s Age?
Yes
Child has had: ___Rubella
___Chicken Pox
___Mumps
BP: ____________/_________________
No
___Rubeola
Other Illnesses:____________________________________________________________________________________
Surgeries:________________________________________________________________________________________
Medication Allergies:_______________________________________________________________________________
Immunizations (Give Dates):
Tetanus:___________
T.B.___________
Pos___
If tetanus date is not available, medical personnel will be allowed to administer a tetanus shot.
Neg___
Home Glucose Meter Used:_______________________________________
Value of Child’s Last A1c: __________________________
Date: ____/_____/__________
How would you rate this child’s diabetes control?
Good Fair
Poor
This child is compliant with dietary management?
Yes
No
This child is compliant with insulin management?
Yes
No
Child checks blood glucose:
Frequently
Average
Child needs extra supervision with diet, insulin, checking:
Yes
No
Children will be supervised with above listed procedures.
I
Circle all that apply:
Child is prone to
Rarely
*Ketoacidosis *Hypoglycemia *Unrecognized Hypoglycemia *Hypoglycemic Seizures *Nocturnal Hypoglycemia
Please Circle All that Apply:
Insulin Make:
Lilly
Novo
Aventis
Other__________________
Insulin Type: Regular
Humalog
Novolog
Lantus
NPH
Levemir
Lente
Other__________________________
Insulin Doses: AM_____________ Noon____________ Supper____________ Bedtime______________
Injection Type:
Pen
Pump
Syringe
Please Note Any Abnormal Findings:
H.E.E.N.T.______________________________________________________________________________
Chest/Cardiac____________________________________________________________________________
Abdomin________________________________________________________________________________
3
Extremities______________________________________________________________________________
Neurological_____________________________________________________________________________
Condition of Injection Sites_________________________________________________________________
Does the child have any other chronic condition, illness, or disease other than diabetes? Yes No
If yes, explain:___________________________________________________________________________
List any medications: Medication
Dose
Time Administered
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
I approve of this child attending camp?
Yes
No
During the child’s stay at camp, s/he will be monitored as closely as conditions permit. Every effort will be
made to maintain your basic management program; however, minor changes are often needed in dosage or
diet due to the level of activity to maintain optimal control. If you wish that no altercations are made during
camp, please indicate below.
_____I approve that medical staff may make changes to my patient’s dosages/diet.
_____I do not want changes in dosages/diet made for my patient except for hypoglycemia.
_____I approve that dosages/diet changes be made, but return to original after camp.
Physician’s Signature______________________________________
Date___________________
Physician’s Printed Name__________________________________________
Address_____________________________________________________________________________
Phone____________________________________
Fax_________________________________
Email__________________________________________________________
This form must be turned in for camper acceptance. Physicians, please fax completed forms to 317-243-4488.
May also be mailed to DYFI, 817 S. Tibbs Ave, Indianapolis, IN 46241.
DYFI Medical Director
Andrew C. Riggs MD
Director, Pediatric Endocrinology and Diabetes
Peyton Manning Children's Hospital at St. Vincent
8402 Harcourt Road, Suite 300
Indianapolis, IN 46260
317-338-3100
4
INCOME ELIGIBILITY FORM
FOR THE
SUMMER FOOD SERVICE PROGRAM
(For Use by Camps and Closed Enrolled Sites)
Please complete the following form using the instructions below. Sign the form and return it to: Diabetes
Youth Foundation of Indiana If you need help, call 317-750-9310
Follow these instructions, if your household gets SNAP TANF or FDPIR:
Part 1: List participant’s name and a SNAP, TANF or FDPIR case number.
Part 2: Skip this part.
Part 3: Skip this part.
Part 4: Sign the form. A Social Security Number is NOT required.
Part 5: Answer this question if you choose to.
If your household includes a FOSTER CHILD, use one application for the whole household and follow these
instructions:
Part 1: Enter the child’s name.
Part 2: Please contact us at [phone number of Sponsor]
Part 3: Complete this part if you are applying for other children in the household and you did not enter a SNAP,
TANF or FDPIR case number in Part 1.
Part 4: Sign the form. If Part 3 was completed, provide the last four digits of the signing adult’s Social Security
Number.
Part 5: Answer this question if you choose to.
ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:
Part 1: List each participant’s name.
Part 2: Skip this part.
Part 3: Follow these instructions to report total household income from last month.
Column A–Name: List the first and last name of each person living in your household, related or not (such as
grandparents, other relatives, or friends who live with you). You must include yourself and all children living with you.
Attach another sheet of paper if you need to.
Column B–Gross income last month and how often it was received. Next to each person’s name, list each type of
income received last month, and how often it was received.
In Box 1, list the gross income each person earned from work. This is not the same as take-home pay. Gross income is
the amount earned before taxes and other deductions. The amount should be listed on your pay stub, or your boss can
tell you. Next to the amount, write how often the person got it (weekly, every other week, twice a month, or monthly).
In box 2, list the amount each person got last month from welfare, child support, alimony.
In box 3, list Social Security, pensions, and retirement.
In box 4, list ALL OTHER INCOME SOURCES including Worker’s Compensation, unemployment, strike benefits,
Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), disability benefits, regular contributions from
people who do not live in your household. Report net income for self-owned business, farm, or rental income. Next to
the amount, write how often the person got it. If you are in the Military Housing Privatization Initiative do not include
this housing allowance.
Column C–Check if no income: If the person does not have any income, check the box.
Part 4: An adult household member must sign the form and include the last four digits of his or her Social
Security Number, or mark the box if he or she doesn’t have one.
Part 5: Answer this question if you choose to.
Privacy Act Statement: This explains how we will use the information you give us.
Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly.
5
Part 1. Children enrolled in Camp or Closed Enrolled Sites.
Names
(First, Middle Initial, Last)
SNAP, TANF or FDPIR case # (if any). Skip to Part 4 if you
listed a case #.
Part 2. Foster Child
Foster children are eligible for free and reduced-price meals regardless of household income. If a foster child lives with you, please
contact [name of Sponsor] at [phone number]. Complete Part 3 if you are applying for other children in your household and
you did not enter a SNAP, TANF or FDPIR case number in Part 1.
Part 3. Total Household Gross Income—You must tell us how much and how often
B. Gross income and how often it was received
Example: $100/monthly $100/twice a month $100/every other week $100/weekly
A. Name
(List everyone in household, 1. Earnings from work
including children)
before deductions
(Example)
Jane Smith
$200/weekly_____
$______/________
$______/________
$______/________
$______/________
$______/________
$______/________
$______/________
2. Welfare, child
support, alimony
3. Social Security,
pensions,
retirement,
4. All Other
Income
$150/weekly_____
$______/_______
$______/_______
$______/_______
$______/_______
$______/_______
$______/_______
$______/_______
$100/monthly_____
$______/________
$______/________
$______/________
$______/________
$______/________
$______/________
$______/________
$______/_______
$______/_______
$______/_______
$______/_______
$______/_______
$______/_______
$______/_______
$______/_______
C.
Check
if NO
income
Part 4. Signature and Social Security Number (Adult must sign)
An adult household member must sign this form. If Part 3 is completed, the adult signing the form must also list the last four digits of
his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on the back of
this page.)
I certify that all information on this form is true and that all income is reported. I understand that this information is being given for the
receipt of Federal funds. I understand that SFSP officials may verify the information. I understand that if I purposely give false
information, the participant receiving meals may lose the meal benefits, and I may be prosecuted.
Sign here: X______________________________Print name:_____________________________Date: ______________
Address:_______________________________________________________Phone Number:______________________
Last four digits of Social Security Number: __ __ __ __  I do not have a Social Security Number
Part 5. Participant’s ethnic and racial identities (optional)
Mark one ethnic identity:
Mark one or more racial identities:
 Hispanic or Latino
Asian
 American Indian or Alaska Native
 Not Hispanic or Latino
White
 Native Hawaiian or Other Pacific Islander
Black or African American
Don’t fill out this part. This is for official use only.
Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12
Total Income: ____________ Per:  Week,  Every 2 Weeks,  Twice A Month,  Month,  Year
Household size: ________
Categorical Eligibility: ___ Date Withdrawn: ________ Eligibility: Free___ Reduced___ Denied___
Reason: ________________________________________________________________________________________
Temporary: Free_____ Reduced_____ Time Period: ___________________________ (expires after _____ days)
Determining Official’s Signature: _______________________________________________ Date: ______________
Confirming Official’s Signature: ________________________________________________ Date: ______________
Follow-up Official’s Signature: _________________________________________________ Date:______________
6
Camper _____________ ______________ Birth date ______ Sex__ Session(s)________
Last Name
First Name
Financial Aid Request
We must receive all forms required forms (including Summer Food Service Program to be eligible for a campership.)
Financial Aid and Camperships: This section must be filled out completely.
DYFI policy states that all eligible children can attend regardless of amount of fee family can pay. We ask that
all families pay as much of the fee as they can so that we may assist as many campers as possible. A sliding
scale is used to determine scholarship awards. Please note: By applying for financial assistance I/We give
permission to DYFI to use our name and our child’s name when seeking campership assistance specifically for
our family. Additionally, you may apply for camperships on top of financial aid awarded. Parent/Guardian
must sign: __________________________________________________
1. Based on your current income, additional amount you can pay $___________________________
2. I already have a sponsor (name)________________________ They have pledged: $____________
3. Total Household Income – for everyone living in household & biological parents living outside home
Place of Employment
Position Monthly
Income before taxes
Mother _______________________
____________________
____________________
Father
_______________________
____________________
____________________
Step-parent _______________________
____________________
____________________
Step-parent _______________________
____________________
____________________
Grandparent _______________________
____________________
____________________
4. Other Sources of Income: Child Support (monthly): $ _______________ monthly
Disability, social security, retirement, unemployment: $ _______________ monthly
5. Other required information:
Is camper in foster care? YES NO Caseworker Name & phone number: ______________________
Is household eligible for food stamps? YES NO
If YES, number:________________________
Is camper eligible for reduced school lunch? YES NO Is camper eligible for free school lunch YES NO
Is camper eligible for Medicaid (Medicaid does NOT pay for camp) YES NO (# required)_________
Is camper seen by Children’s Medical Services (CMS)? YES NO (# required) ___________________
CMS Care Coordinator Name: __________________________Phone __________________________
6. Is there a special financial situation that may require our consideration?
___________________________________________________________________________________
___________________________________________________________________________________
Please apply as early as possible for financial aid and scholarships as resources are limited. Families are
encouraged to contact service clubs, business, churches, and organizations such as Kiwanis, Rotary, Lions,
Eagles, Veteran’s Groups, etc in your area your area for sponsorships. We must have a copy of the previous
year’s federal tax form, page 1, showing combined income of family or single returns for each parent. You
cannot qualify for additional financial side without these forms.
7
Camper _____________ ______________ Birth date ______ Sex__ Session(s)________
Last Name
First Name
Campership Request
(Can be requested by everyone, even those who applied for financial aid)
We must receive all required forms (including Summer Food Service Program to be eligible for a campership.)
Request for:
_____$150 Partial Campership
_____$300 Partial Campership
_____$350 Partial Campership
_____$400 Partial Campership
_____$500 Full Campership
Are you applying for financial aid also?
___Yes
___No
Have you contacted any service groups about possible sponsorship (Lions, Kiwanis, etc.) ___Yes ___No
If yes, who and what was their response? _______________________________________________________
________________________________________________________________________________________
Did you participate in the calendar fundraiser?
___Yes
___No
Number of members in household? _______________
Total annual household income? _________________
The following question is for the camper:
What does camp mean to you? (If first year, what are you most excited about for camp?)
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
8
Camper _____________ ______________ Birth date ______ Sex__ Session(s)________
Last Name
First Name
Payment Form
In order to reserve a spot at the camp, we must receive a $50 deposit with all of the forms.
Please choose one of the following:
_____Enclosed you will find a check for $______________
_____I would like to use the following credit card (Please write legibly)
Card #:_______________________________________________________ Exp. Date: __________
Security Code: __________ Zip Code: ______________
Charge for:
_____$50 Deposit
_____Full $500 Payment
_____Other Amount: ___________________
Signature: _________________________________________________ Date: __________________
Note: DYFI does not discriminate based upon race, sex, national origin, age, and religion.
9
Camper Packing Guide
Please remember when packing for camp, pack old clothes. The kids will be taking creek hikes, along with
other fun activities. Please pack enough clothes and supplies for the entire week. Kids will not be able to use
the laundry facility. The following will be taken away and kept in office: cell phones fans; personal sports
equipment, swim fins, masks, and snorkels; food, candy, knives, axes, and all cutting tools; matches, sparklers,
caps, etc: cigarettes, any other valuables. Tobacco use and flammables are also not allowed on DYFI property.
DYFI is not responsible for any items lost, stolen, or left at camp.
Clothing
Shirts
Sweatshirt
Shorts
Pants
Underwear
Socks
Pajamas
Swim Suit
Laundry Bag
Sneakers
Water Shoes/Sandals
Amount
7
2
6
2
7
9 Pair
3
1
1
2 Pair
1 Pair
Packed?
Other Items
Towels
Toiletries
Sunscreen
Bug Spray
Twin Sheets
Pillow
Pillowcase
Blanket
Flashlight
Water Bottle
Envelopes/Stamps
Amount
2
Week Worth
1
1
1
1
1
1
1
1
(Optional)
Packed?
If you have any questions while packing, please contact Jenna Holt at [email protected].
Note: Parent(s)/guardian(s) will be notified of an illness or injury to their child by the camp medical staff.
Documentation will be placed in the camper’s folder and take home medical report shared with parents and
camper home physicians. All medication (including OTC) is stored, maintained and administrated by the
Medical Staff. Campers and staff assessed by medical director for health, injuries, and head lice during check
in.
Day Camp Only:
Please write name on every item brought to camp. Many times, items are left behind or are similar to others.
Clothing: Please send in comfortable clothes, as they will be very active. Plan for the weather.
Lunch: Please pack a lunch with carb card. Lunches will be refrigerated. Snacks will be provided.
Swim Gear: Please pack a swimsuit, sandals, towel, and sunscreen each day.
Diabetes Supplies: If your child uses a pump, please send extra supplies. (Insulin, testing supplies, and
needles/syringes are provided by DYFI.)
Please leave cell phones and other devices at home.
10
Check-In and Check-Out Information
The Diabetes Youth Foundation of Indiana is eagerly awaiting the arrival of your child. The staff will undergo an
extensive training program to ensure that your child’s stay is both enjoyable and safe. We are well aware of the
significance of the trust you have placed in us by enrolling your child in our camping program. All of us at the Diabetes
Youth Foundation of Indiana’s Camp Until a Cure will do our very best to show you that this trust was well placed. We
feel that each counselor, program, and medical staff member must be comfortable with diabetes and prepared for any
potential problem, just as you are. Please relax and enjoy the time that your child spends with us. We are confident your
child will have a great time while learning more about managing diabetes.
Check-in Times:
All Sessions: Campers last names starting with letters A-L: 1:30 p.m.
Campers last names starting with letters M-Z: 2:30 p.m.
All campers should be at camp no later than 3:30 p.m. so that we can begin evening insulin on time.
Should you need special arrangements for check-in, please contact Dave Dozier at 317-224-0190 by June 5th for Session
1, June 12th for Session 2, and June 19th for Session 3. After those dates, please call 317-750-9310.
Check-in Procedure:
Check-in will take place in the dining hall. Park in the front parking lot and walk to the dining hall. (There will be
people directing where to park.) All campers should check in to receive cabin assignments and to review all medical
information for changes. Any medications and pump supplies should be given to the cabin medical staff at check-in. As
part of the check-in process, there will be a pump nurse table and dietitian table to review pumps settings (unless a
downloaded pump setting summary was provided) and diet. After checking in and meeting your med staff, then a
counselor will assist you to your cabin.
Mail:
Getting mail at camp is exciting for any child. It takes a few days for mail to get to us; mail sent after the last
Wednesday of your child’s session will probably not arrive in time. Use the following address:
Child’s Name
C/O Camp Until a Cure
th
5050 East 211 Street
Noblesville, IN 46060
Don’t be surprised if you don’t hear back from your child during his or her stay at camp. This often means that things
are going well. We will encourage letters home.
Phone:
Due to a limited number of phone lines, we do not permit children to make routine calls. Also, we have found that calls
home usually result in homesickness. If an emergency should arise, the camp number is 317-877-1721 or the 317-7509310.
Check-Out:
When you arrive, please meet at your child’s cabin. We will have a short wrap up of the week’s events along with a
family picnic (weather permitting.)
Session 1: June 14th at 10:00 a.m.
Session 2: June 21st at 10:00 a.m.
Session 3: June 28th at 10:00 a.m.
Check-out Procedure:
We are very proud of our program at Camp Until a Cure and look forward to this opportunity to show you what your
child has experienced during his or her stay. Important information about your child’s diabetes will be included in the
check-out material. It is essential that you pick up medical and dietary information to ensure a smooth transition back to
home activity. Camp is right around the corner! We eagerly await your child’s arrival. For any questions, please feel free
to call Jenna Holt at 317-750-9310. See you at camp!!
11
Day Camp Check-In and Check-Out Information
The Diabetes Youth Foundation of Indiana is eagerly awaiting the arrival of your child. The staff will undergo an
extensive training program to ensure that your child’s stay is both enjoyable and safe. We are well aware of the
significance of the trust you have placed in us by enrolling your child in our camping program. All of us at the Diabetes
Youth Foundation of Indiana’s Camp Until a Cure will do our very best to show you that this trust was well placed. We
feel that each counselor, program, and medical staff member must be comfortable with diabetes and prepared for any
potential problem, just as you are. Please relax and enjoy the time that your child spends with us. We are confident your
child will have a great time while learning more about managing diabetes.
Check-In:
Session 1: June 16th-20th
Session 2: June 23rd -27th
Please arrive promptly at 9:00 a.m.
Park in the main parking lot and walk your child to the registration table to check in. Please be cautious as
there will be children playing in the area. Any medications or personal items should be given to the medical
staff at check in. Day campers will have a secure place for their belongings.
Check-Out:
Please arrive promptly at 3:00 p.m. each day to pick your child up. You will be given a sheet of the day’s
activities.
Be prepared to sign your child in and out each day. If another person besides the designated parent checks in
or out, please notify DYFI staff in writing prior to check out. A photo ID will be required to check your child
out.
If you have any questions, please contact Jenna Holt at 317-750-9310.
12
Directions to Camp Until A Cure
Camp Address: 5050 East 211th Street, Noblesville, IN 46060
Note: If using GPS, ensure directions lead you to 211th Street off of Hinkle Road and not by Little Chicago Rd.
Coming from the North on State Road 31
Exit at State Road 38 East towards Noblesville
Travel 2 miles East to the intersection of Hinkle Road (northbound) and Moontown Road (southbound)
Turn North (left) onto Hinkle Road
Travel 1mile North to 216th Street.
Turn East (right) on 216th Street at our DYF Camp sign.
Travel a ¼ mile on the black top road to camp gravel road.
Turn North (left) onto the camp gravel road.
Follow the signs to camp.
Speed Limit is 10 MPH.
Coming from the South on State Road 31 – Via I-465
Take State Road 31 North from I-465
Travel past Westfield exit State Road 32
Exit at State Road 38 East towards Noblesville
Travel 2 miles East to the intersection of Hinkle Road (northbound) and Moontown Road (southbound)
Turn North (left) onto Hinkle Road
Travel 1mile North to 216th Street.
Turn East (right) on 216th Street at our DYF Camp sign.
Travel a ¼ mile on the black top road to camp gravel road.
Turn North (left) onto the camp gravel road.
Follow the signs to camp.
Speed Limit is 10 MPH.
From the East – Travel from Noblesville West on State Road 38 to Hinkle Road
Turn North (left) onto Hinkle Road
Travel 1mile North to 216th Street.
Turn East (right) on 216th Street at our DYF Camp sign.
Travel a ¼ mile on the black top road to camp gravel road.
Turn North (left) onto the camp gravel road.
Follow the signs to camp.
Speed Limit is 10 MPH.
From the West – Travel from Sheridan East on State Road 38 to Hinkle Road
Pass under State Road 31
Travel 2 miles East to the intersection of Hinkle Road (northbound) and Moontown Road (southbound)
Turn North (left) onto Hinkle Road
Travel 1mile North to 216th Street.
Turn East (right) on 216th Street at our DYF Camp sign.
Travel a ¼ mile on the black top road to camp gravel road.
Turn North (left) onto the camp gravel road.
Follow the signs to camp.
Speed Limit is 10 MPH.
13