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Diabetes at the RCH

Request a School Camp Plan

  • Hello, 

    This form will submit a request for a diabetes school camp plan.   

    Going on school camp can be an exciting adventure for children. Sometimes parents are worried that the school will not know how to look after their child's diabetes care needs. A dedicated school camp plan prepared by your diabetes team will help the teachers plan how best to support your child.  


    Preparing a plan takes time so requests must be made at least 4 weeks before your school needs it.  Please answer the following questions and the diabetes team will send your child's camp plan via email.  

    Details 

     Child's name: 

     Date of birth:

    Hospital record number (if known)

     Last HbA1c and date of collection:

     Current year level at school:

     

     Name of school: 


    Diagnosis of coealiac disease?

    Parent/carer name and relationship to child: 

    Parent/carer phone number: 

    Parent/carer 2 name ad relationship to child: 

    Parent/carer 2 phone number:

    What is the best contact email to return the completed plan to you? 

    Do you give permission for us to email the plan to the above email provided?

    Camp dates: 

    Camp duration: 

     

    Is the camp location more than 30 minutes away from emergency services? 

    If yes, we recommend that staff learn how to administer glucagon.

      Names of buddy teachers attending camp:


     

    Will a parent/carer be attending camp?

     

    Camp activity level: 

     Other: 

     

    Hypoglycaemia treatment on camp: 

    What type of fast acting carbohydrates are used (sugar serve)?

    List the type and quantity. 


    What type of slow acting carbohydrates are used as follow up treatment? 

    List the type and quantity. 


     

    Insulin modality and doses:

    An insulin dose reduction will likely be recommended for the duration of camp.  

    PLEASE NOTE:

    Insulin regimen currently using: 

    Insulin injections: 

    What time of the day is the long acting insulin given i.e. glargine, Ryzodeg or Levemir? 


    If using injections or pens complete these questions.

    If using an insulin pump, skip through this section and complete the next section on insulin pumps.  

     

    Insulin administration type: 

    Blood glucose level (BGL) checking: 

    Does your child independently check BGLs?

    If no, who will support your child with BGL monitoring on camp? 

     

    Flexible dosing for injections: 

    Names and doses of current insulin: 

    If dosing cards are used, indicate carbohydrate and correction ratios 

    Twice daily insulin. Indicate name of insulin and current doses: 

    Multiple daily injections using fixed doses. Indicate the name of the insulin and current doses: 


     

    Multiple daily injections using flexible dosing. 

    Name of insulin used: 


    For dosing cards or bolus app e.g. MyLife, indicate carbohydrate and correction ratios (located on the top of the card or in the settings part of your app under "bolus calculator settings")

    Carbohydrate ratios: 

    Insulin sensitivity/correction settings: 
     

    Insulin pumps: 

    Complete this section if using an insulin pump.

    Insulin pump brand: 

     Other type of pump not listed above: 

    Date of last pump upload:

    To complete a camp plan we must have a current pump upload:


    What type of insulin cannula does your child use? 
    Other type of line: 

    Student pump skills: 
    Can your child change their own pump cannula and reservoirs? 
    Can your child give an insulin injection in case of line failure, pump failure or if ketones are 0.6 mmol/L or higher? 
    Can your child independently count carbohydrates? 
    If you answered no to any of the pump skills questions, indicate the plan for management on camp:

    Continuous glucose monitoring (CGM) or flash glucose monitoring (FGM)

    On camp, will your child be using CGM/FGM? 
     If yes using CGM or FGM, what brand are they using? 

     Other type of CGM/FGM: 

     


    Can your child change a CGM/FGM sensor if needed? 

     For CGM and insulin pumps, does your child use any of these features:

          Other: 


    Copy and paste any information you feel is needed to prepare your child's camp plan or add any additional information:

    Additional information and equipment: 

    A list of supplies will be included in the camp plan. Your child needs to take twice the amount of equipment and insulin they might expect to use, including ketone strips and a spear BGL meter. 

    When clicking submit, please wait for the page to load. We are finding it is taking time to process and multiple pushes of the submit button creates multiple requests. A confirmation page will come up when the form has been emailed to diabetes@rch.org.au

    If you are unsure if the form has been processed contact diabetesadmin@rch.org.au