Living Well with Diabetes: Now and in the Future

REGISTRATION FORM

Living Well with Diabetes: Now and in the Future

Please note: There are separate registration forms for adults, children (infants to 8 years),tweens (ages 9-12) and teens (ages 13-17). Please photocopy extras as needed. Please note there will be no childcare available at the conference.

REGISTRATION FORM- ADULT

Name______

Address______

______

CityStateZip

Best phone number to reach you______

Would you like to request a gluten free meal? (Please circle) YesNo

Choose one break-out session to attendat 10:30 a.m.

____ Research Update on Islet Transplantation

____ What Color Is Your Brain?®: Family Communication and Diabetes

____ How To Advocate for Your Child With Type 1

Choose one break-out session to attend at 12:45 p.m.

____ Everything You Wanted to Know About Continuous Glucose Monitoring (CGM)

____ What Is Encapsulation Therapy?

____ Round Table: Raising Your Child With Type 1 Diabetes Across the Developmental Spectrum

____ What Color Is Your Brain?®: Family Communication and Diabetes

REGISTRATION FORM – TEEN (ages 13-17)

Name______

Address______

______

CityStateZip

Best phone number to reach you ______

Would you like to request a gluten free meal? (please circle) Yes No

Choose one break-out session to attend at 10:30 a.m.

____ Research Update on Islet Transplantation

____ What Color Is Your Brain?®: Family Communication and Diabetes

____ How To Advocate for Your Child With Type 1

Choose one break-out session to attend at 12:45 p.m.

____ Everything You Wanted to Know About Continuous Glucose Monitoring (CGM)

____ What Is Encapsulation Therapy?

____ Round Table: Raising Your Child With Type 1 Diabetes Across the Developmental Spectrum

____ What Color Is Your Brain?®: Family Communication and Diabetes

Registration Form – TWEEN (Ages 9-12)

If not attending the SPECIAL Tween’s program, child must be accompanied by an adult to another break-out session.

Name______Age_____

Address______

______

CityStateZip

Would you like to request a gluten free meal? (please circle) Yes No

Choose one break-out session for your tweento attendat 10:30 a.m.

_____ Tweens Program: Moving to Independence - Part 1 (Recommended)

If selecting from below, tween must attend with adult.

_____ Research Update on Islet Transplantation

_____ What Color Is Your Brain?®: Family Communication and Diabetes

_____ How To Advocate for Your Child With Type 1

Choose one break out session for your tweento attend at 12:45 p.m.

____ Tweens Program: Moving to Independence - Part 2 (Recommended)

If selecting from below, tween must attend with adult.

____ Everything You Wanted to Know About Continuous Glucose Monitoring (CGM)

____ What Is Encapsulation Therapy?

____ Round Table: Raising Your Child With Type 1 Diabetes Across the Developmental Spectrum

____ What Color Is Your Brain?®: Family Communication and Diabetes

REGISTRATION FORM – CHILD (infant to 8 years)

Name______Age_____

Address______

______

CityStateZip

Would you like to request a gluten free meal? (please circle) Yes No

Choose one break-out session for your child to attend WITH YOU at 10:30 a.m.

____ Research Update on Islet Transplantation

____ What Color Is Your Brain?®: Family Communication and Diabetes

____ How To Advocate for Your Child With Type 1

Choose one break-out session for your child to attend WITH YOU at 12:45 p.m.

____ Everything You Wanted to Know About Continuous Glucose Monitoring (CGM)

____ What Is Encapsulation Therapy?

____ Round Table: Raising Your Child With Type 1 Diabetes Across the Developmental Spectrum

____ What Color Is Your Brain?®: Family Communication and Diabetes

Payment

TOTAL

_____ number of adults ($35 per person)______

_____ number of children 17 and under ($35 per person)______

*Total Attending______x $35 = FINAL TOTAL ______

PLEASE make check or money order to JDRF. Please send payment and completed registration form(s) to:

Living Well with Diabetes: Now and in the Future

JDRF

225 City Line Avenue Suite 104

BalaCynwyd, PA 19004

If you have any questions, Contact Judy Ayala from CHOP at 215-590-2428 or contact Dan Lennon from JDRF at 610-227-0361.

*1 x $35 = $35

2 x $35 = $70

3 x $35 = $105

4 x $35 = $140

5 x $35 = $175

6 x $35 = $210