Camp Trios 2025 Application

Camper Registration

WHO: Children ages 6 to 14 with type 1 diabetes

WHAT: Learning & having fun!

WHERE: Southridge Sports Complex
2901 Southridge Blvd, Kennewick, WA 99337

WHEN: Tuesday July 15th 8:30 am to 4:30 pm
Wednesday July 16th 8:30 am to 4:30 pm
Thursday July 17th 8:30 am to 4:30 pm

Question Title

* 1. Registration Checklist
All checklist items are due May 31, 2025

Completed application with signed consent

Signed authorization to treat

A head shot photo of your child: email to Trios.DiabetesEducation@trioshealth.org

$80.00 payment *Please ask for scholarship application if unable to cover fee. Please remit payment to: Trios Health Diabetes and Nutrition Education 3730 Plaza Way, Suite 6600, Kennewick, WA 99338
509-221-5442

Question Title

* 2. Camper Registration Information

Camper Name

Nickname

Address

City/Town

State/Province

ZIP/Postal Code

Camper's Birth Date

Email Address

Phone Number

Question Title

* 3. Sex

Male

Female

Question Title

* 4. Parent/Guardian

Name

Child's age at Diabetes onset

Address

City/Town

State/Province

ZIP/Postal Code

Child's age at camp

Email Address

Phone Number (please include cell number and best way to contact you)

Question Title

* 5. Other person(s) authorized to pick child up or contact in case of emergency

Name:

Relationship:

Phone Number:

Name:

Relationship:

Phone Number:

Question Title

* 6. Insurance information:
In the event of any need for medical care outside of the camp setting, insurance information for your child may be needed. Please complete the following:

Insurance Company Name:

Address:

Policy Number:

Name of Insured Family Member:

Insured Member's Place of Employment:

Is pre-authorization required?

Question Title

* 7. Tell us about your child:
Would you describe the camper as one who (check all that apply)

Is Sensitive

Makes Friends Easily

Is Moody

Is Easygoing

Is Easily Led

Is Strong-willed

Leads Others

Is Rebellious

Is Fearful

Question Title

* 8. Does your child get along with others?

Yes

Question Title

* 9. Is your child excited about coming to camp?

Yes

Question Title

* 10. Can your child swim?

Yes

Question Title

* 11. Is there any information that would help us ensure your child has the best camp experience possible?

Question Title

* 12. T-Shirt Size:

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult X-Large

Adult XX-Large

Question Title

* 13. Medical Information:
Does your child use an insulin pump?

Yes

Question Title

* 14. If yes, what brand and model:

Question Title

* 15. Does your child usually give own insulin injections or use pump without assistance?

Yes

Question Title

* 16. List name of insulin used:

Question Title

* 17. Carbohydrate ratios:

Question Title

* 18. Correction Factors:

Question Title

* 19. Blood glucose targets for correction factors:

Question Title

* 20. Does your child bolus before or after meals?

Question Title

* 21. Will your child need help with blood glucose tests?

Yes

Question Title

* 22. Does your child recognize signs of low blood sugar?

Yes

Question Title

* 23. What are the usual symptoms of low blood sugar for your child?

Question Title

* 24. Is your child using Continuous Glucose Monitoring (CGM)?

Question Title

* 25. If yes, what type?

Question Title

* 26. Does the CGM communicate with their pump?

Yes

Question Title

* 27. Has your child ever had seizures?

Yes

Question Title

* 28. Will your child need to take any other medication besides insulin during camp hours?

Yes

Question Title

* 29. Please list any other medications, dosage, & schedule for your child:

Question Title

* 30. Please list specific accommodations needed or other health concerns we should be aware of:

Question Title

* 31. Camp Menu

Our camp menu is not finalized as we will work with our mentors to ensure camper satisfaction. We will have a BBQ on the last day. We'll send the menu out the week before camp for review.

*menu will have gluten free options

NOTE: Two snacks a day and all entrees will include fruit, vegetable and water

Food allergies or special accommodations to menu:

Question Title

* 32. CONSENT:
I hereby give my consent for adjusting insulin dose, injecting insulin, performing blood tests, or any medical care deemed necessary by camp physicians, nurses and dietitians. I will not hold liable Camp Trios, Trios Health or any individual associated with the Camp, for accidental injury or illness resulting from this camper’s attendance and camp activities. I understand a camp setting is different than the home setting and management of my child’s diabetes schedule, while medically supervised at camp, will need to be flexible.

Signature of Parent/Guardian:

Date:

Question Title

* 33. Camp Trios publicity Release Form:
Trios Health, and/or the local news media (i.e., TV, newspaper, radio) has my permission to take my child's picture, and/or interview my child, for local news stories while my child is a participant of Camp Trios.

I understand that I may or may not appear, or be mentioned, in said news story and require no financial or other remuneration for this. I understand that I have the right to rescind during taping or filming, not after the product is completed.

Release applies to dates of Camp Trios only – July 15, 16 and 17, 2025
Trios Health staff will oversee all interviews and photos.

Name of Child:

Name of Parent/Guardian:

Signature of Parent/Guardian:

Address:

Phone Number:

Camp Trios is committed to making a difference in the lives of children with diabetes, ensuring that they have the opportunity to live a healthy life and enjoy a safe environment to gather while learning to be self-disciplined and responsible.

Trios Health Diabetes and Nutrition Education
3730 Plaza Way, Suite 6600
Kennewick, WA 99338

509-221-5442
Trios.DiabetesEducation@trioshealth.org

Once you click on submit application, the application has been submitted. You will begin to receive emails regarding camp about 4 weeks prior to Camp Trios. Should you have any questions prior to that time please email or phone us using the information above. Thank you

Camp Trios 2025 Application

Camper Registration

Question Title

* 1. Registration ChecklistAll checklist items are due May 31, 2025

Question Title

* 2. Camper Registration Information

Question Title

* 3. Sex

Question Title

* 4. Parent/Guardian

Question Title

* 5. Other person(s) authorized to pick child up or contact in case of emergency

Question Title

* 6. Insurance information:In the event of any need for medical care outside of the camp setting, insurance information for your child may be needed. Please complete the following:

Question Title

* 7. Tell us about your child:Would you describe the camper as one who (check all that apply)

Question Title

* 8. Does your child get along with others?

Question Title

* 9. Is your child excited about coming to camp?

Question Title

* 10. Can your child swim?

Question Title

* 11. Is there any information that would help us ensure your child has the best camp experience possible?

Question Title

* 12. T-Shirt Size:

Question Title

* 13. Medical Information:Does your child use an insulin pump?

Question Title

* 14. If yes, what brand and model:

Question Title

* 15. Does your child usually give own insulin injections or use pump without assistance?

Question Title

* 16. List name of insulin used:

Question Title

* 17. Carbohydrate ratios:

Question Title

* 18. Correction Factors:

Question Title

* 19. Blood glucose targets for correction factors:

Question Title

* 20. Does your child bolus before or after meals?

Question Title

* 21. Will your child need help with blood glucose tests?

Question Title

* 22. Does your child recognize signs of low blood sugar?

Question Title

* 23. What are the usual symptoms of low blood sugar for your child?

Question Title

* 24. Is your child using Continuous Glucose Monitoring (CGM)?

Question Title

* 25. If yes, what type?

Question Title

* 26. Does the CGM communicate with their pump?

Question Title

* 27. Has your child ever had seizures?

Question Title

* 28. Will your child need to take any other medication besides insulin during camp hours?

Question Title

* 29. Please list any other medications, dosage, & schedule for your child:

Question Title

* 30. Please list specific accommodations needed or other health concerns we should be aware of:

Question Title

Question Title

Question Title

* 1. Registration Checklist
All checklist items are due May 31, 2025

* 6. Insurance information:
In the event of any need for medical care outside of the camp setting, insurance information for your child may be needed. Please complete the following:

* 7. Tell us about your child:
Would you describe the camper as one who (check all that apply)

* 13. Medical Information:
Does your child use an insulin pump?