ConnecT1D · 2018 ConnecT1D Middle School Retreat

Contact Information

Camper Name

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Birthdate

*

(mm/dd/yyyy)

Age

Gender Identity

Parent/Guardian

*

First Name

Last Name

Preferred Pronoun

Parent/Guardian Email

Verify Email

Camper Phone #

Parent/Guardian Phone #

*

Camper Email

Verify Email

2nd Parent/Guardian Name

First Name

Last Name

Camper T-shirt Size

Dietary Restrictions

We will work to meet the dietary needs of campers. Note: the kitchen will be providing meals to other groups on site that week, so the kitchen will not be entirely gluten/dairy/etc. free. Please let us know in the comments if camper has strict preparation safety needs.

Vegetarian

Gluten Free

Dairy Free

Nut Allergy

2nd Parent/Guardian Phone #

2nd Parent/Gaurdian Email

Verify Email

Other accomodations?

We will do our best to meet needs as event allows

Diabetes Management

T1D Diagnosis Date

*

(mm/dd/yyyy)

Years since T1D Diagnosis

(Scale of 1-10) I am able to independently manage my Type 1 Diabetes without assistance

How do you check your blood sugar and administer insulin? (Meter/CGM/Pump/MDI)

What brand devices do you use (Omnipod, Medtronic, T-slim, etc.)

I check my blood sugar overnight

I am able to check my blood sugars overnight independently

If not independent, what types of assistance do you usually receive at home?

Other Medical Issues we should be aware of at camp?

(Scale of 1 to 10) How confident do you feel in your management of your T1D?

(Scale of 1 to 10) I have a strong community of people in my life that understand living with T1D

What do you hope to get out of the ConnecT1D Middle School Retreat?

Registration Fees

Non-refundable Deposit: All campers registering are required to pay a $10 registration fee at time of registration.

Registration Fee Structure:

Full Fare registration is the true cost per person attending camp.
Full and partial scholarships are available through generous grant support for campers whose family income qualifies as low-income or are facing economic hardship. Proof of household income must be submitted at time of application. Scholarship applications will be processed on a first come, first served basis.

Payment Due Date:

Full Fare Fees must be paid at time of registration.
Scholarship Applicants will be notified by July 15th whether granted scholarship support. Remaining balance is due July 30th.

Scholarship

Need-based scholarships are available

I would like to apply for a scholarship for support beyond the subsidized rate

Registration Type

*

$300 - Full Fare (Due at time of registration)

$150 - Subsidized Fee (Due after notification of scholarship)

$10 - Scholarship Application Fee (Due at registration, while application is reviewed)

Household Size

Household Annual Income

Upload Proof of Income (REQUIRED for scholarship application)

Most recent paystub or household 2017 tax documents

Scholarship Request Notes

Scholarship Application Deposit Required

Don't forget to select the $10 scholarship deposit option above and pay to hold your spot while we review scholarship applications.

Camp Policy Agreement and Waivers

Please read our ConnecT1D Middles School Retreat Policies in entirety and accept below.

Policy & Waiver Agreement

*

I agree to the policies and waiver listed above on behalf of all family members listed in this registration.

E-signature of legal adult representative filling out this form

*

ConnecT1D social media, newsletters, and involvement

Have you attended a ConnecT1D Event before? If so, which ones?

I'm interested in

Joining the ConnecT1D E-newsletter list

Volunteering at an event

Medical Information Submission

Note: Prior to camp you will be contacted for more details on camper diabetes regiment and health history. These forms must be submitted prior to attending camp. Watch emails for more details and make sure your email inbox is set to accept emails from @connect1d.org email addresses.