Diabetes Youth Foundation of Indiana Diabetes Camp 2020

 

The Diabetes Youth Foundation of Indiana (DYFI) is a local 501c3 non-profit with a mission and passion to educate, encourage, and empower children living with Type 1 diabetes, while providing support to their families. We serve hundreds of youth every year through our Residential Summer Camp, Day Camp, Family & Teen Weekends, Ambassador Program, and other outreach opportunities. Our camp is located in Noblesville, IN and serve all of Indiana.

Required forms:
Please download, fill out and scan the following two forms. There will be an opportunity to upload and submit these completed documents on the form below.
Medical History and Liability Form (2 pages)
Affidavit & Release Form

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Name
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Email
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Telephone
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Address1
Address2
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City
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State
select
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Zip
  
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Date of birth:
Please provide license number (if applicable):
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Title:










If you marked "Student" or "Other Healthcare Provider" above, please provide additional information/area of study or expertise:
Credentials (if applicable):
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Place of employment (if applicable)
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Position or title:
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Last year of school completed (or year you graduated):
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Please provide your emergency contact information, including address and day/evening phone number:
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Do you have malpractice insurance?
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Have you worked at a diabetes camp in the past?
If yes, where?
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Please describe your work experience:
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Please describe your experiences with diabetes:
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What are your goals/reasons for attending diabetes camp?
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CAMP SCHEDULE: My first preference is the week of:
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CAMP SCHEDULE: My second preference is the week of:
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CAMP SCHEDULE: My third preference is the week of:
If there is a week you are not available, please select:
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What is your tee shirt size:
Please upload your completed Medical History Form:
(Allowed extensions: *.doc, *.docx, *.jpeg, *.jpg, *.pdf, *.png)
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Please upload your completed Affidavit Disclaimer Form:
(Allowed extensions: *.doc, *.docx, *.jpeg, *.jpg, *.pdf, *.png)
SUBMIT