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2017 ConnecT1D Retreat Registration
A. Event Tickets
Ticket
*
Quantity
$249
-
T1D Adult ticket (Double Occupancy)
0
1
1
$299
-
T1D Adult ticket (Single Occupancy)
0
1
1
$199
-
T3 (Partner/Spouse)
0
1
1
You selected a T3 ticket. This is only allowed if you are accompanying a T1 partner/spouse who has already purchased a double occupancy room. If so, what is their name?
Please add the below amount to my total as a donation to ConnecT1D programs.
$
Name of roommate (if choosing a double-occupancy room)
Roommate Pending
I don't have a roommate, but plan to find one and notify ConnecT1D by March 15th. I understand that if I cannot find a roommate, I will be charged an additional $5o for a single room upgrade.
Roommate Pending
B. Attendee Registration Details
Birthdate
*
(mm/dd/yyyy)
T1D Adult
*
First Name
Last Name
Gender
T1D Diagnosis Date
(mm/dd/yyyy)
Phone
Email
*
Verify Email
*
Phone Type
select one
Mobile
Home
Work
Facebook Username
E-communications
Sign me up to receive more info about:
General ConnecT1D events/updates
Adult Social Group Meetups
Team ConnecT1D/Get Fit events
Volunteer Opportunities
T-shirt Attendee #1
*
Choose adult unisex t-shirt size
select one
X-small
Small
Medium
Large
X-Large
XXL
XXXL
Dietary Restrictions (T1D participant)
Vegetarian
Vegan
Dairy Free
Gluten Free
Nut Allergy
Primary Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Other accommodations needed at event?
C. (Optional) Guest #2 Registration
Are you attending with a T3 Spouse/Partner? If so, please answer below. If not, skip to Section D. If rooming with another T1D participant, they must fill out a separate registration form.
Guest #2
First Name
Last Name
Guest #2 Birthdate
(mm/dd/yyyy)
Guest #2 Gender
Guest #2 Email
Verify Email
Dietary Restrictions (Guest #2)
Vegetarian
Vegan
Dairy Free
Gluten Free
Nut Allergy
E-communication s
Sign me up for more info on:
General ConnecT1D events/updates
T3/Partners of T1Ds topics
Guest #2: Other accommodations needed at event?
T-shirt Attendee #2
Choose adult unisex t-shirt size
select one
X-small
Small
Medium
Large
X-Large
XXL
XXXL
D. Pre-Conference Questionaire
Tell us a little more about your Type 1 experience, so we can tailor the retreat to best serve you!
Why did you register for the ConnecT1D retreat and what are you hoping to come away with?
Do you have a support person such as a spouse, partner, or friend attending the retreat with you?
Yes
No
How often do you feel supported in your diabetes care and needs by your friends & family?
Always
Often
Sometimes
Not at all
What barriers reduce your ability to manage your diabetes will? (mark all that apply)
Financial burdens
Limited or no insurance coverage for needed services
Limited support from friends and family
Do not feel co-workers or classmates understand my diabetes needs and care
Having to deal with other medical conditions
Other barriers (write in box below)
Other barriers
How often are you connected with the Type 1 Diabetes Community?
weekly
monthly
a couple times/year
annually
rarely
I don't know others with Type 1
How much have your connections to others with type 1 diabetes positively impacted your diabetes management?
A great deal
Much
Somewhat
Little
Not at all
I do not have these connections
How do you deal with any stress or burnout from managing your diabetes? (write in box below)
Do you agree or disagree with the following statements?
I have the skills I need to best manage my diabetes care
select one
Strongly Agree
Agree
Disagree
Strongly Disagree
Diabetes interferes with my relationships with others
select one
Strongly Agree
Agree
Disagree
Strongly Disagree
I feel overwhelmed by my diabetes and its impact on my life
select one
Strongly Agree
Agree
Disagree
Strongly Disagree
Living with diabetes has made me a stronger person
select one
Strongly Agree
Agree
Disagree
Strongly Disagree
I experience guilt or self-criticism around my diabetes management
select one
Strongly Agree
Agree
Disagree
Strongly Disagree
I hope for a healthy life with diabetes
select one
Strongly Agree
Agree
Disagree
Strongly Disagree
I feel powerless managing my diabetes
select one
Strongly Agree
Agree
Disagree
Strongly Disagree
I feel isolated because of my diabetes
select one
Strongly Agree
Agree
Disagree
Strongly Disagree
I am satisfied with my latest A1c results
select one
Strongly Agree
Agree
Disagree
Strongly Disagree
What is your biggest challenge living with diabetes?
What medical supports do you regularly use to manage your diabetes? (mark all that apply)
Inject insulin
Insulin pump
Continuous glucose monitor (CGM) to check blood glucose levels
Glucose meter often to check blood glucose levels
Diabetes education and nutrition centers
What types of events would you be interested in attending?
Adult social meet-ups
Group fitness activities for all ability levels
Competitive and/or endurance team events for athletes
Volunteer opportunities to work with kids, teens, and/or families living with T1D
Other (write in box below)
Other
Thank you for your input!
How did you hear about the Retreat
Add 3% to my total amount to help cover the payment processing fees