Kidney Disease Form Page 2
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2Standard Precautions/Adaptations for Kidney Disease and Kidney Transplant
1) All campers have their weight and BP checked upon arrival to RRR.
2) Blood Pressures are checked and recorded for all campers each morning and as needed.
3) Weights are checked daily for all campers who are on Peritoneal Dialysis, and as needed.
4) Campers are encouraged to drink 2-3 liters of fluids/day unless they have a fluid restriction. Fluid recommendations are ad-
justed slightly at camp to prevent dehydration from outdoor activities in the heat of summer. The adjustment is based on camp-
ers’ activity levels each day and the outdoor temperature.
5) We provide a healthy diet that is low in cholesterol and refined sugars, and includes freshly prepared food at every meal. Dur-
ing our kidney session we provide a basic Renal Diet this is low in sodium (<1500 mg/day) and avoids foods high in potassium
and phosphorous.
For campers with specific dietary requirements not served by the basic renal Diet, we work with our dietary team to ensure that
each camper’s dietary needs are met.
Dietary restrictions/requirements outside of basic Renal Diet outlined above?
□ YES
□ NO (If YES, provide details below)
Sodium restriction: less than ____mg/day
Higher Sodium diet: greater than _____mg/day
Potassium restriction
Higher potassium diet
Phosphorous Restriction
Fluid restrictions/requirements outside the 2-3 Liters/day outlined above?
□ YES
□ NO (If YES, provide details below)
Fluid Restriction: Maximum fluid intake of _____Liters/day OR _____ounces/day
Push fluids: Minimum Fluid intake of ______Liters/day OR ______ounces/day
Camp Program/Activity Area Adaptations: (Please check all that apply)
No Contact Sports
Padding to be applied at the climbing wall/zip line for :
□ Kidney Transplant
Location of kidney:_______________________
□ Ostomy
Type:__________________________________ Location:_________________________
□ Catheter
Type:__________________________________ Location;_________________________
□ Stoma
Type:__________________________________ Location:_________________________
□ Port
Type:__________________________________ Location:_________________________
□ Other
Type:__________________________________ Location:_________________________
Water Related Activity Restrictions (We do NOT have a swimming pool) :
Peritoneal Dialysis catheter
Date of surgery:______________________________
Immunosuppression Precautions
No boating
Shower only / no bathing
No activities that involve spraying or squirting of water
Participation in activities involving water with accommodations:
□ Cover port with occlusive dressing
□ Cover catheter with occlusive dressing
□ Other
Please describe;_____________________________________________________
Fax completed form to 888-524-2477 or email to
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