ConnecT1D · 2017 Team ConnecT1D Registration Form

Contact Information

Name

*

First Name

Last Name

Email

*

Verify Email

*

Phone

Address (So we can send you the Team visor)

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Birthday

*

Some events may require 18 or 21 years of age.

Gender

(You may skip this field if you would prefer to not provide this information)

What is your connection to Type 1 Diabetes?

*

How did you hear about Team ConnecT1D?

*

What events from our 2017 calendar interest you?

Additionally, are there events that you would like to see Team ConnecT1D pursue in the future?

Member Profile Picture

This will be used for your member profile on the Team ConnecT1D Page. If you would prefer to not include a picture, or not have a profile, this field is not necessary.

Please provide a brief bio for your member profile on our Team ConnecT1D webpage. This can contain age, hometown, particular interests, your T1 story, etc.

If you would prefer to not provide this information, leave this section blank.

*

By checking this box, I understand that the organization ConnecT1D is not responsible for any injury that may occur during any events as part of Team ConnecT1D. I agree that I am medically able and properly trained to complete any and all events I register for on my own. I hereby release ConnecT1D, its partners and affiliates, from any and all liability/claims arising from participation with Team ConnecT1D.

Amount

*

$15

(Optional - if you already have a visor, or fancy yourself more of a sombraro person)

I do not need a visor, and prefer to donate the full $15 to ConnecT1D