Peak Power Sports Individual Diabetes Care Plan (IDCP)

*For Use in Peak Power Sports After School and Sports Camps

Child's Information:

Child’s Name: ___________________________

Date of Birth: ___________________________

Parent/Guardian Names: ___________________________

Emergency Contact Numbers:

Parent/Guardian 1: ___________________________

Parent/Guardian 2: ___________________________

Alternate Contact: ___________________________

Primary Healthcare Provider: ___________________________

Provider’s Contact Information: ___________________________

Date of IDCP Creation: ___________________________

IDCP Reviewed By: ___________________________

(Parent, Coach, Healthcare Provider)

1. Diabetes Information

Type of Diabetes: (Circle one)

Type 1 Diabetes / Type 2 Diabetes / Other: ___________________________

Date of Diagnosis: ___________________________

Usual Blood Sugar Range: ___________________________

(e.g., 80-120 mg/dL)

Target Blood Sugar Range for Sports Activities: __________________________

2. Blood Sugar Monitoring

Frequency of Blood Sugar Checks During Activities:

- Before activity: ___________________________

- During activity: ___________________________

- After activity: ___________________________

Preferred Blood Glucose Meter: ___________________________

Who performs the blood sugar check?

- The child: ___________________________

- Staff/Coach assistance required: ___________________________

Symptoms of Low Blood Sugar (Hypoglycaemia) Specific to This Child:

______________________________________________________________

Symptoms of High Blood Sugar (Hyperglycaemia) Specific to This Child:

______________________________________________________________

3. Hypoglycaemia Management (Low Blood Sugar)

Symptoms to watch for:

(Check or add all that apply)

☐ Shakiness

☐ Sweating

☐ Irritability

☐ Dizziness

☐ Confusion

☐ Weakness

☐ Pale skin

☐ Other: ____________________________________________

*Treatment for Low Blood Sugar:

- Administer fast-acting glucose (e.g., juice, glucose tablets, or other):

______________________________________________________________

- Amount to give: ___________________________

- Retest blood sugar after __________ minutes.

- If blood sugar remains low, give additional: ___________________________

Rest Time Needed After Treatment:

- Minimum time before returning to play: ___________________________

Emergency Action Plan for Severe Hypoglycaemia:

- Administer glucagon: ___________________________ (Dose/Instructions)

- Call 999 and notify parents/guardians immediately.

4. Hyperglycaemia Management (High Blood Sugar)

Symptoms to watch for:

(Check or add all that apply)

☐ Increased thirst

☐ Frequent urination

☐ Fatigue

☐ Blurred vision

☐ Nausea/vomiting

☐ Other: ____________________________________________

Treatment for High Blood Sugar:

- Allow the child to drink water: ___________________________

- Monitor for worsening symptoms (e.g., rapid breathing, fruity breath, confusion).

- Retest blood sugar after __________ minutes.

- Administer additional insulin if needed (per healthcare provider’s instructions):

______________________________________________________________

Emergency Action Plan for Severe Hyperglycaemia:

- If blood sugar remains elevated or symptoms worsen, call 999 and notify parents/guardians immediately.

5. Insulin Administration

- Does the child use insulin during sports activities? (Yes / No)

- Type of insulin used: ___________________________

- Usual insulin dose: ___________________________

- Instructions for Insulin Administration:

- Before activity: ___________________________

- During activity: ___________________________

- After activity: ___________________________

- Who administers insulin?

- The child: ___________________________

- Staff/Coach assistance required: ___________________________

6. Nutrition and Snacks

- Snack Times and Frequency:

- Pre-activity snack: ___________________________

- During activity snack: ___________________________

- Post-activity snack: ___________________________

- Recommended Snacks for Treating Low Blood Sugar:

- Type and amount: ___________________________

- Special Dietary Restrictions or Preferences:

______________________________________________________________

7. Physical Activity Adjustments

Activity Modifications:

- Are there any limitations or modifications needed for physical activity?

(Yes / No) If yes, specify: ___________________________

Signs of Fatigue or Distress to Watch for During Activities:

______________________________________________________________

Procedure if Child Needs to Stop Activity Due to Blood Sugar Issues:

- Allow rest for __________ minutes.

- Retest blood sugar.

- Ensure proper hydration and nutrition.

- Notify parents if symptoms persist or worsen.

8. Emergency Contacts and Procedure

- **Primary Emergency Contact:** ___________________________ (Name & Phone)

- **Secondary Emergency Contact:** ___________________________ (Name & Phone)

- **Healthcare Provider Contact:** ___________________________ (Name & Phone)

**999 should be called if:**

- The child becomes unconscious.

- The child has a seizure.

9. Supplies Provided by Parent/Guardian

- Diabetes Supplies (e.g., glucose meter, test strips, insulin, glucagon, snacks):

______________________________________________________________

Parent/Guardian Acknowledgment:

I agree to provide the necessary diabetes supplies and update the IDCP as needed.

Parent/Guardian Signature: ___________________________

Date: ___________________________

10. Coach/Staff Acknowledgment

- Coach/Staff Responsible for Implementing This Plan:

Name: ___________________________

Acknowledgment of Responsibility:

I have read and understand the diabetes management plan for the child and will follow it as outlined.

Coach/Staff Signature: ___________________________

Date: ___________________________

This IDCP is to be updated annually or as the child’s diabetes management needs change.

Next Review Date: ___________________________