- Diabetes Treatments

Registration forms page 1 of 15
Campamento Diabetes Safari 2007

Telephone / Teléfono: 52 55 5510
9830

The 7 forms needed to register for Campamento Diabetes Safari 2007 are
presented here

The 7 separate forms can be printed, filled out by hand, signed, and mailed
or delivered to the address indicated below

The forms required for each Campers registration include:
1 This page, on which the total or partial payment made is noted
page 1
2 Application form pages 2 - 3
3 Photo face of the Camper, only if this is his/her first time at
this Campamento
4 Personal information about the Camper page 4
5 Information about the management and self-management of DM1 pages
5 - 7
6 Medical report pages 8 - 9
7 Teachers recommendation pages 10 - 11
8 Legal authorization and agreement form pages 12 - 14
9 Check or copy of deposit slip stamped by HSBC Bank, if payment is
by bank deposit

Send a single copy of all registration forms plus a photo of the Campers
face if this is his/her first time at this Campamento and a check or copy
of the
bank deposit slip to:

|The total cost of Campamento Diabetes Safari 2007 is: 2400 Mexican|
|pesos or 240 U S dollars The cost
is the same for all Campers, |
|regardless of home country |
| |
|Please note the amount that you are enclosing to register the |
|Camper: _______________________ the minimum deposit accepted is|
|1200 Mexican pesos or 120 U S dollars, without exception |
| |
|Balance __________________________ to be paid before 26 April |
|2007 |
| |
|The deadline for receipt of the registration forms and any balance |
|due is 26 April 2007, without exception |
| |
|Payment may be made in cash, bank deposit to account 06106282875 |
|of HSBC Bank, or by personal or certified check payable to Dr |
|Stan De Loach |
| |
|If registration is canceled before 3 April 2007, an
administrative |
|charge of 500 Mexican pesos or 50 U S dollars will be retained |
|from reimbursement of the amount paid, without exception |
| |
|If registration is canceled after 3 April 2007, neither full nor |
|partial reimbursement of the registration fee paid will be made, |
|without exception |
Application form page 2 of 15
Campamento Diabetes Safari 2007

|CAMPER |
| |
|Name |Last name |
|__________________________|________________________________________|
|____ |_____ |

|Age as of 12 May|_________ |
|2007 |years |
| |
|Grade in school: |
|______________________ |

|Campers address |
| |
|Street |
|____________________________________________________________|
|__________________ |
|City |State |
|______________________________|_____________________________|
|_______ |______ |
|Zip Code ________________ |Country |
| |_____________________________|

|Phone numbers for Camper and her/his
parents |
|Home __________________________________ |
|Cellular ______________________________________ |
|_____________________________________ |
|E-mails _____________________________________ |
|_____________________________________ |

Persons who live in the same house with the Camper
|Mother |yes |no | |
| |_______ |_______ | |
|Father |yes |no | |
| |_______ |_______ | |
|Brother|yes |no | |
|s |_______ |_______ |_______|
|Sisters|yes |no | |
| |_______ |_______ |_______|
|Others|yes |no | |
| |_______ |_______ |_______|

page 3 of 15
|Campers father |
| |
|Name |Last name |
|____________________________|_____________________________________|
|____ |___ |
| | |
|Date of birth |day,
month, year ______ |
| |______ ______ |

|Address only if different from |
|Campers address |
| |
|Street |
|________________________________________________________________|
|___________________ |
|City |State |
|__________________________________ |____________________________|
| |_____ |
|Zip Code________________ |Country |
| |____________________________|
| |_ |

|Fathers employer |
|________________________________________________________________|
|_______ |

|Type of |___________________________________________________|
|work |____________________ |
|Position or|___________________________________________________|
|title |____________________ |

|Campers mother |
| |
|Name |Last name |
|______________________________|__________________________________|
|_____ |__ |
| | |
|Date of birth |day, month, year ______ |
| |______ ______ |

|Address only if
different from |
|Campers address |
| |
|Street |
|________________________________________________________________|
|___________________ |
|City |State |
|__________________________________ |____________________________|
| |_____ |
|Zip Code________________ |Country |
| |____________________________|
| |_ |

|Mothers employer |
|_________________________________________________________________|
|______ |

|Type of |___________________________________________________|
|work |____________________ |
|Position or|___________________________________________________|
|title |____________________ |

Personal information about the Camper page 4 of 15
Campamento Diabetes Safari 2007

|CAMPER |
| |
|Name |Last name |
|_____________________________|__________________________________|
|_____ |__ |

The Camper

establishes friendships with persons who
are
|younger |older |of the same age|
|____ |____ |____ |

has spent the night outside the family home, separated from his/her family
|yes |no |where? |
|____ |____ |___________________________________|
| | |_____ |
| |
|For how long?|___________________________________|
| |____ |

wets the bed at night
|yes |no |
|____ |____ |

walks in her/his sleep
|yes |no |
|____ |____ |

dresses and gets ready slowly
|yes |no |
|____ |____ |

eats very slowly
|yes |no |
|____ |____ |

has a good appetite
|yes |no |
|____ |____ |

is allergic to foods, medicines, or drugs
|yes |no |which ones? |
|____ |____ |_________________________________________________|
| | |______ |

knows how to swim
|yes |no |
|____ |____ |

has the following
interests and hobbies
|_____________________________________________________________|
|_________________________ |

wants to attend this Campamento
|yes |no |If no, please explain the reasons: |
|____ |____ |______________________________________ |

has a problem or difficulty of which the Director of the Campamento should
be aware
|yes |no |If yes, please explain: |
|____ |____ |__________________________________________________ |

Information about the management and page 5 of 15
self-management of diabetes, type 1
Campamento Diabetes Safari 2007

|CAMPER |
| |
|Name |Last name |
|_____________________________|__________________________________|
|_____ |__ |

|The Campers endocrinologist |
|Name |Last visit day, |
|_________________________________________|month, year |
|_____ | |
|
|________ ________ |
| |________ |
|Telephone | |
|_________________________________________| |
|_____ | |

|The Campers pediatrician |
|Name |Last visit day, |
|_________________________________________|month, year |
|_____ | |
| |________ ________ |
| |________ |
|Telephone | |
|_________________________________________| |
|_____ | |

|Types of human insulin that the Camper currently uses |
| |
|Note: During the Campamento, Campers and Staff with DM1 use only|
|basal insulin glargine/Lantus and prandial insulin lispro/Humalog|
|or, rarely,
insulin aspart/NovoRapid |
| |
|Lantus |yes |no ____ | |
|glargine |____ | | |
| | | | |
|Humalog |yes |no ____ | |
|lispro |____ | | |
| | | | |
|NovoRapid |yes |no ____ | |
|aspart |____ | | |
| | | | |
|Regular R |yes |no ____ | |
| |____ | | |
| | | | |
|NPH |yes |no ____ | |
| |____ | | |
| | | | |
|Others |yes |no ____ Which ones? |
|
|____ |_____________________________ |

|Dosages of human insulin injected |
| Type Units |
|/ Type Units |
|Before |_________________________________ |
|breakfast |/_________________________________ |
|Before lunch|_________________________________ |
| |/_________________________________ |
|Before |_________________________________ |
|dinner |/_________________________________ |
|At bedtime |_________________________________ |
| |/_________________________________ |
|To correct hyperglycemia type and of units |
|___________________________________________ |

The Camper

applies his/her own insulin injections

|yes ________ |no ________ |
|with supervision |without supervision ________ |
|________ | |
|If no, who injects
|_____________________________________|
|the insulin? |______________ |

page 6 of 15
draws up the dose of insulin for injection

|yes ________ |no ________ |
|with supervision |without supervision ________ |
|________ | |
|If no, who prepares |__________________________________|
|the dose? |______________ |

performs blood glucose self-monitoring to check her/his blood sugar levels

|yes ________ |no ________ |
|with supervision ________ |without supervision |
| |________ |
|If no, who performs blood |______________________|
|glucose monitoring? |_________ |

applies complementary doses of insulin when blood glucose is elevated

|yes ________ |no ________ |
|If yes, when are |______________________________________|
|they used? |_______________ |
|If yes, how
|______________________________________|
|frequently? |_______________ |

has other medical conditions

|yes |no |If yes, which ones? |
|____ |____ |____________________________________________________ |

takes other medicines besides insulin

|yes |no _____ |
|____ | |
|If yes, which ones? |
|Name |__________________|Dose|________|Frecuenc|__________________|
| |______ | |___ |y |_______ |
|Name |__________________|Dose|________|Frecuenc|__________________|
| |______ | |___ |y |_______ |
|Name |__________________|Dose|________|Frecuenc|__________________|
| |______ | |___ |y |_______ |

experiences hypoglycemia without warning or symptoms

|yes |no |
|____ |____ |

experiences severe hypoglycemia, with loss of consciousness and/or
convulsions

|yes |no |
|____ |____ |

|What are the Campers personal signs or symptoms of low blood |
|sugar hypoglycemia? |

|hunger |never |

|How does the Camper treat low levels of blood glucose? |
|
|
|________________________________|________________________________|
|____________ |____________ |

|Reason for last |______________________________________|
|hospitalization |_______________ |

|Does the Camper follow a food plan prescribed by a |
|physician, Diabetes |
|Educator, or dietitian? |
| yes|no ____ |
|____ | |

|Total daily calories|____________|
| |____ |
|Number of meals |____________|
|daily |____ |
|Number of snacks |____________|
|daily |____ |
| | |
|Total carbohydrates
|____________|
|daily |____ |
|Carbohydrates at |____________|
|breakfast |____ |
|Carbohydrates at |____________|
|lunch |____ |
|Carbohydrates at |____________|
|dinner |____ |
|Carbohydrates in |____________|
|snacks |____ |

|How are food portions decided? |
| |
|by weight grams, |yes |no |
|ounces |_____ |_____ |
|by measures cup, |yes |no |
|teaspoon |_____ |_____ |
|by estimating |yes |no |
|visually |_____ |_____ |
|by counting |yes |no |
|carbohydrates |_____ |_____ |

|What is the physical activity level |
|of the Camper? |

|Very |______|Somewhat |______|Generally |______|
|active |_ |active |_ |inactive |_ |
page 8 of 15
Medical report
Campamento Diabetes Safari 2007

|CAMPER |
| |
|Name |Last name |
|____________________________|_____________________________________|
|_____ |___ |

|Eyes |normal|____|abnorma|____|comments|______|
| | |_ |l |_ | |__ |
|Ears |normal|____|abnorma|____|comments|______|
| | |_ |l |_ | |__ |
|Throat |normal|____|abnorma|____|comments|______|
| | |_ |l |_ |
|__ |
|Thyroid |normal|____|abnorma|____|comments|______|
| | |_ |l |_ | |__ |
|Lungs |normal|____|abnorma|____|comments|______|
| | |_ |l |_ | |__ |
|Heart |normal|____|abnorma|____|comments|______|
| | |_ |l |_ | |__ |
|Abdomen |normal|____|abnorma|____|comments|______|
| | |_ |l |_ | |__ |
|Digestive system |normal|____|abnorma|____|comments|______|
| | |_ |l |_ | |__ |
|Genitourinary |normal|____|abnorma|____|comments|______|
|system | |_ |l |_ | |__ |
|Menstruation |normal|____|abnorma|____|comments|______|
| | |_ |l |_ | |__ |
|Skin |normal|____|abnorma|____|comments|______|
| | |_ |l |_ | |__ |
|Neurologic |normal|____|abnorma|____|comments|______|
|functioning | |_ |l |_ | |__ |
|Psychological |normal|____|abnorma|____|comments|______|
|functioning
| |_ |l |_ | |__ |

|Epilepsy |
|yes |no |comments |
|____ |____ |_______________________________________________|
| | |________ |

|Asthma |
|yes |no |comments |
|____ |____ |_________________________________________________|
| | |_________ |

|Has the Camper had chickenpox? |
|yes ____ |no ____ |comments |
| | |___________________________________________|
| | |______ |

|Has the Camper been exposed to any contagious disease in the |
|last month? |
|yes ____|no ____|which |
| | |ones?_______________________________________|
| | |____________ |

|Has the Camper been vaccinated for tetanus [tetanus toxoid DTaP]|
|in the past 10 years?
|
|yes ____|no ____|when?___________________________________________|
| | |___________ |

page 9 of 15

|Does the Camper have celiac disease? |
|yes |no |treatment?_________________________________________|
|____ |____ |____________________ |

HbA1c hemoglobina glucosilada
| | | | |
|Date|day, month, year ________ |Resul|_____________|
| |________ ________ |t |___ |
|Date|day, month, year ________ |Resul|_____________|
| |________ ________ |t |___ |
|Date|day, month, year ________ |Resul|_____________|
| |________ ________ |t |___ |

Other medicines prescribed and currently taken do not include insulin
|______________________________|______________________________|
|____________ |____________ |
|______________________________|______________________________|
|____________ |____________
|

NOTE: Vaccination against Hepatitis B is recommended, due to risks of
accidental pricks with the needles or lancets used in the control of
diabetes mellitus, type 1

COMMENTS:

I examined the above-named child/adolescent and I certify that the state of
her/his health does not represent an obstacle to participation in
activities during Campamento Diabetes Safari 2007

|Signature ____________________________________ |
| |
|Name please print |
|______________________________________________ |
| |
|Specialty _______________________________________|
| |
|Address |
|_________________________________________________|
|_________ |
| |
|_________________________________________________|
|___________________ |
| |
|Telephone number
|
|__________________________________ |
| |
|E-mail_____________________________________ |
| |
|day, month, year ________ ________ |
|________ |

|Deadline for receipt of this report is 2 May 2007, |
|without exception |

Thank you for your support
Teachers recommendation page 10 of 15
Campamento Diabetes Safari 2007

|CAMPER |
| |
|Name |Last name |
|_____________________________|___________________________________|
|_____ |___ |

|Grade in |__________________|
|school |______ |

|For how long have
you known the|____________________________|
|Camper? |___________ |
| | |
|How many hours does she/he |____________________________|
|spend in your |___________ |
|classes each day? | |
| | |
|Subjects that you teach |____________________________|
|him/her |___________ |

|Do you believe that the Camper has sufficient emotional |
|maturity to benefit from |
|educational and recreational programs in a Camp for children |
|and adolescents |
|with diabetes mellitus, type 1? |
| |
|yes ______ | |
|perhaps | |
|______ | |
|no ______ |comments
|
| |________________________________________________|
| |_______ |

|Does the Camper need extra help or special |
|attention in order to learn? |
| |
|yes ______ |no ______ |

|How does the Camper relate with other students|
|of the same age? |

|very well |well |poorly |very poorly | |
|______ |______ |______ |______ | |
| |
|comments |
|_____________________________________________________|
|___________ |

|How does the Camper relate |
|to adults? |

|very well |well |poorly |very poorly | |
|______ |______ |______
|______ | |
| |
|comments |
|_____________________________________________________|
|___________ |

page 11 of 15

|yes ______ |
|perhaps ______ |
|no ______ |
|comments |
|________________________________________________________________|
|_______________ |

|yes ______ |
|perhaps
______ |
|no ______ |
|comments |
|________________________________________________________________|
|_______________ |

|Signature |______________________|day, month, year ____ |
| |________ |____ ____ |
| | | |
|Teachers name |______________________| |
| |________ | |
| | | |
|Schools name |______________________| |
| |________ | |
| | | |
|Schools address |Street |
| |_______________________________________________|
| |____________ |
| |City
|State |
| |______________________|_________________________|
| |___ |__ |
| |Zip Code |Country |
| |____________________ |_________________________|
| | | |
|Schools phone |______________________|_________________________|
|numbers |________ |_____ |
| | | |
|E-mail |______________________| |
| |________ | |

|Deadline for receipt of this recommendation is 2 May 2007, |
|without exception |

Thank you for your support
Legal authorization and agreement page 12 of 15
Campamento Diabetes Safari 2007
Centro Vacacional Oaxtepec
Yautepec, Morelos, México
12 - 15 May 2007

|CAMPER |
| | |
|Name
|Last name |
|____________________________|______________________________________|
|____ |___ |
| | |

|I hereby apply for admission of my son or daughter, |
|______________________________________ name, to Campamento Diabetes |
|Safari 2007 for children and adolescents with diabetes mellitus, type |
|1 I consent to my daughters or sons being given the food plan, |
|doses of insulins, and daily blood glucose monitoring as deemed |
|optimal by the professional staff in charge of diabetes care at the |
|Campamento I consent to my sons or daughters being given other |
|care and testing that may be medically necessary while he or she is |
|participating in the Campamento |
| |
|I understand that participation in the Campamento Diabetes Safari 2007|
|program is voluntary I am aware of the legal stipulations that |
|state, in part, that all persons who undertake an educational |
|excursion
waive all claims against the organizers, their agents, |
|suppliers, and employees and agree to hold the organizers, their |
|agents, suppliers, and employees harmless in case of injury, accident,|
|illness, death, or acts of omission or commission occurring during or |
|as a result of the educational excursion |
| |
|With this Legal authorization and agreement and in consideration of |
|Campamento Diabetes Safari 2007s allowing my daughter or son to |
|attend the Camp, I hereby release Campamento Diabetes Safari 2007, its|
|agents, suppliers, sponsors, donors, employees, assigns, volunteers, |
|and entire Staff from any and all liability and responsibility, for |
|any reason, arising out of and in connection with her or his |
|participation |
| |
|The Campamento does not provide insurance coverage Aware of this |
|fact, I authorize my son or daughter, whose name appears above, to |
|participate in the 4-day program, as it is
described on the main |
|webpage wwwcontinentscom/diabetes-safari07htm and related webpages,|
|which I have reviewed and read in electronic or printed form All |
|consequences deriving from the omission of information related to the |
|health, medical or special needs of the Camper are the responsibility |
|of the Camper and his or her parents The Campamento does not provide|
|inter-city bus transportation to Campers; rather, transportation to |
|and from the site of the Campamento the Centro Vacacional Oaxtepec, |
|is the responsibility solely of the Campers family |
| |
|The Campers parents will personally transport her/him to Campamento |
|Diabetes Safari, on Saturday, 12 May 2007, in order for her/him to |
|arrive between 8 am and 10 am |
| |
|Yes ____ |
|No____ |
| |
|
|
|If No, what arrangements ensure his/her on-time arrival at the |
|Campamento? |
| |
|______________________________________________________ |
| |
| |
|The Campers parents will personally pick her/him up on Tuesday, 15 |
|May 2007, between 4 pm and 5 pm |
| |
|Yes ____ |
|No____ |
| |
| |
|If No, what arrangements ensure his/her on-time departure from the |
|Campamento? |
|
|
|______________________________________________________ |
| |

I am aware of and will respect the policy established for the Campers
arrival on 12 May 2007, between 8 am and 10 a m, and for her/his
departure on 15 May 2007, between 4 pm and 5 pm
page 13 of 15

| |
|In case it should be impossible to locate or communicate with the |
|Campers parents, below are the names and contact information of two |
|2 persons or alternates whom the Staff of the Campamento may contact|
|in case of an emergency and to whom the Camper may be delivered, if |
|necessary |
| |
|Name |
|_____________________________________________ |
| |
|
|
| |
|Relation to Camper? _____________________________________________ |
| |
| |
| |
|Telephone |
|home / work |
|___________________________________ |
| |
| |
| |
| |
|cellular |
|___________________________________ |
| |
| |
|
|
| |
|e-mail |
|___________________________________ |
| |
| |
| |
| |
|Name |
|_____________________________________________ |
| |
| |
| |
|Relation to Camper? _____________________________________________ |
| |
| |
|
|
|Telephone |
|home / work |
|___________________________________ |
| |
| |
| |
| |
|cellular |
|___________________________________ |
| |
| |
| |
| |
|e-mail |
|___________________________________ |
| |
|
|
| |
| |
|I freely and fully authorize my daughters or sons current health |
|care providers including, but not limited to, physicians, registered |
|nurses, diabetes educators [certified or not], registered dietitians, |
|psychotherapists, psychologists, teachers, etc to release to the |
|Staff of Campamento Diabetes Safari 2007 all relevant information |
|about my son or daughter and his or her health and treatment for any |
|chronic or acute medical condition, including diabetes mellitus, type |
|1 |
| |
|The Campamento Staff does everything possible to ensure that clothing |
|and other personal articles remain the property of their owner, but |
|does not accept responsibility for lost, destroyed, or stolen objects|
|If the emotional or psychological conditions or the physical behavior |
|of the Camper cause detriment to the harmony and productive
|
|development of the event, or could be harmful or destructive to the |
|Camper himself or herself, a suspension will result Serious |
|violations of the rules of conduct may result in the Campers |
|expulsion from the program, in which case at any time, day or night, |
|the parents or their alternates will be contacted, so that they can |
|come immediately to the Centro Vacacional Oaxtepec to take custody of |
|and responsibility for the Camper |
| |
|In order to facilitate the prompt medical treatment of my daughter or |
|son, whether because of accident or illness, I hereby consent to all |
|medical or surgical treatment and testing of an emergency nature |
|With my signature, I authorize the physician appointed by the Director|
|of the Campamento to order X-rays, routine laboratory tests, |
|psychological support, and other treatments required for the Campers |
|health; I also give the physician permission to hospitalize and to |
|order injections, anaesthesia, and/or surgery |
|
|
|While Campamento Diabetes Safari 2007 may supply insulins, syringes, |
|blood glucose and ketone monitoring supplies, and routine first-aid |
|care required at Camp without cost to the Camper and his/her family, I|
|assume personal responsibility for all costs associated with other |
|foreseen and unforeseen medical treatments for my daughter or son, |
|including, but not limited to, laboratory tests, x-rays, and emergency|
|treatment at a hospital or clinic |
| |
|By my signature on this Legal authorization and agreement, I authorize|
|the professional Staff of the Campamento to give my son or daughter |
|any and all medicines sent from his or her home |

page 14 of 15

|Medicines sent from home: |
| |
|Medicines sent from home are administered only with the parents |
|written permission
|
|All medicines, including inhalers or nebulizers, are available day and|
|night |
|All medicines must be in their original pharmacy container and should |
|be clearly marked with the Campers name, the name of the medicine, |
|and instructions for the exact dose and times required |
|If the Camper needs an injection of adrenaline such as the Ana Kit or|
|Epi Pen, due to a severe allergic reaction, the adrenaline should be |
|sent in the original pharmacy packaging, with the Campers name and |
|complete instructions for its use |
|The Campers parents are responsible for making a list of all |
|medicines sent with their daughter or son to the Campamento The list|
|should include: the name of the medicine, for which condition it is |
|used, the correct dose, times at which it is administered, indications|
|for its use, and any special instructions |
| |
|I consent to my sons or daughters being photographed by the |
|Campamento Staff, and I agree that any
such photographs may be used, |
|along with his or her first name without the surname, only in |
|printed and/or internet publicity designed to raise funds to support |
|the Campamento in the future |
| |
|I have read, I understand, and I agree to the above-outlined terms and|
|conditions of all waivers and agreements, and in accord with these |
|terms and conditions, I authorize the Camper named above to attend and|
|participate in the programmed activities of Campamento Diabetes Safari|
|2007, from 12 - 15 May 2007, at the Centro Vacacional Oaxtepec, |
|Yautepec, Morelos, México |

|Fathers/Guardians|________________________________________|
|name |________________ |
| |
|Mothers/Guardians|________________________________________|
|name |________________ |

|By my signature, I guarantee that the information given by us in |
|this application form are correct and truthful and
that I am in |
|free agreement and accord with the stipulated conditions: |

|Signature |day, month, year ________ |
|_____________________________________|________ ________ |
|____ | |
|Camper | |
| | |
|Signature |day, month, year ________ |
|_____________________________________|________ ________ |
|____ | |
|Father | |
| | |
|Signature |day, month, year ________ |
|_____________________________________|________ ________ |
|____ | |
|Mother | |

Rules and Behavioral Contract page 15 of 15
Campamento
Diabetes Safari 2007

While I am a Camper at Campamento Diabetes Safari 2007 12 - 15 mayo 2007,
I agree to the following rules and required behaviors:

I will not leave the grounds of the Campamento for any reason

I will not physically or psychologically hurt either myself or any other
Camper

I will not intentionally keep my blood sugars either extremely high or
extremely low

I will avoid consuming foods except at mealtimes, snacktimes, or when
required to treat hypoglycemia

I will not damage or destroy the natural environment, the property of the
Centro Vacacional Oaxtepec, or the personal property of any other person
My family is responsible for the cost of any such damage

I will not scrawl on or write grafitti on the property of other persons

I will avoid acting in ways that conflict with accepted morality and
human customs

I will not tease, harrass, or make negative ethnic, racial, religious, or
political comments toward any person or group, present or absent from the
Campamento

I will not smoke tobacco or use street drugs, alcoholic beverages, or
weapons such as guns or knives

I understand that if I join with another
person who is breaking these
rules, we both will be asked to leave the Campamento

I understand that if I do not follow these rules,
I will be expelled from the Campamento
My parents will be required to withdraw me from the Campamento
No return will be made to my parents for any fees paid to allow me to
participate in the Campamento
I may lose the opportunity to attend the Campamento in the future

I understand that with my signature below I indicate my acceptance of
this behavioral contract with the Campamento Diabetes Safari 2007

_____________________________________________
_____________________________________________
Campers name Campers signature
_____________________________________________
Date

As the Campers mother or father, I have read and I understand the rules in
this contract I will participate in enforcing them I have read and
explained these rules to my son or daughter, and I believe that he or she
understands them I agree to come to withdraw my son or daughter if he or
she does not comply with this contract
_____________________________________________

Name of father or mother
_____________________________________________
Signature of father or mother
_____________________________________________
Date

|Main page: wwwcontinentscom/diabetes-safari07htm |
|Top of this page 2007 |

Source:ayudainc.net

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