ConnecT1D · 2019 Family Camp Registration

Contact Information

Preferred Family Name (for identifying your party, ex: "Smith-Jones")

*

Household Phone #

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

# Adults in Party

*

Parent/Guardian 1 Name

*

First Name

Last Name

Parent 1 Cell Number

*

Parent 1 Email

*

Verify Email

*

Adult #1 Gender

Dietary Restrictions Parent #1

Vegetarian

Vegan

Gluten-Free

Dairy Free

Nut Allergy

Adult #1 Preferred Pronoun

Adult #1 T1D affilitation

I have T1D

I am the Parent of Child with Type 1

Friend/family to someone with Type 1

Date of T1D Diagnosis (Adult #1)

(mm/dd/yyyy)

Attending Parent/Guardian #2 (if applicable)

First Name

Last Name

Parent #2 Cell #

Parent #2 Email

Verify Email

Adult #2 Gender

Dietary Restrictions Parent #2

Vegetarian

Vegan

Gluten-Free

Dairy Free

Nut Allergy

Adult #2 Preferred Gender Prounoun

Adult #2 T1D affilitation

I have T1D

I am the Parent of Child with Type 1

Friend/family to someone with Type 1

Date of T1D Diagnosis (Adult #2)

(mm/dd/yyyy)

Adult #3

First Name

Last Name

Adult #3 Cell #

Adult #3 Email

Verify Email

Adult #3 Gender

Dietary Restrictions Adult #3

Vegetarian

Vegan

Gluten-Free

Dairy Free

Nut Allergy

Adult #3 Preferred Gender Prounoun

Adult #3 T1D affilitation

I have T1D

I am the Parent of Child with Type 1

Friend/family to someone with Type 1

Date of T1D Diagnosis (Adult #3)

(mm/dd/yyyy)

# of Counselor Volunteers (teens 13+/adults) that will be staying in your lodging?

Any volunteer counselors (teens 13+ or adults) that will be staying with your party? Youth age 13+ in attendance, will work with CITs and adult volunteers to support the children's programing. Note: All volunteers must also apply/register through the volunteer portal

Camper Registration

# Children (0-12yo) in party

If you have more than 6 people in your party, please fill out another registration form with same "Family Name" for multiple rooms

Child #1 Name

*

First Name

Last Name

Child #1 Age at Camp

Child #1 Birthdate

*

(mm/dd/yyyy)

Does Child #1 have T1D?

*

Yes

No

Child #1 Gender

Date of T1D Diagnosis (Child #1)

(mm/dd/yyyy)

Child #1 Preferred Gender prounoun

Dietary Restrictions Child #1

Vegetarian

Vegan

Gluten-Free

Dairy Free

Nut Allergy

Child #1 T-shirt

Complimentary T-shirt comes with each child registration

Child #2 Name

*

First Name

Last Name

Child #2 Age at Camp

Child #2 Birthdate

*

(mm/dd/yyyy)

Does Child #2 have T1D?

*

Yes

No

Child #2 Gender

Date of T1D Diagnosis (Child #2)

(mm/dd/yyyy)

Child #2 Preferred Gender Prounoun

Dietary Restrictions Child #2

Vegetarian

Vegan

Gluten-Free

Dairy Free

Nut Allergy

Child #2 T-shirt

Complimentary T-shirt comes with each child registration

Child #3 Name

*

First Name

Last Name

Child #3 Age at Camp

Child #3 Birthdate

*

(mm/dd/yyyy)

Does Child #3 have T1D?

*

Yes

No

Child #3 Gender

Date of T1D Diagnosis (Child #3)

(mm/dd/yyyy)

Child #3 Preferred Gender Prounoun

Dietary Restrictions Child #3

Vegetarian

Vegan

Gluten-Free

Dairy Free

Nut Allergy

Child #3 T-shirt

Complimentary T-shirt comes with each child registration

Child #4 Name

*

First Name

Last Name

Child #4 Age at Camp

Child #4 Birthdate

*

(mm/dd/yyyy)

Does Child #4 have T1D?

*

Yes

No

Child # 4 Preferred Gender Prounoun

Child #4 Gender

Date of T1D Diagnosis (Child #4)

(mm/dd/yyyy)

Dietary Restrictions Child #4

Vegetarian

Vegan

Gluten-Free

Dairy Free

Nut Allergy

Child #4 T-shirt

Complimentary T-shirt comes with each child registration

How did you hear about Family Camp?

When did you first attend Family Camp?

If returning, how many years have you attended Family Camp?

I want more Camp Leo + ConnecT1D info & updates

Sign me up for the e-newsletter

Interested in volunteering before or at camp?

parent volunteers would be asked to do small tasks in preparation for camp or onsite that weekend between sessions (e.g. help serve snack, set up a family activity, etc)

I want to help build T1D connections the community

Would you be willing to host a family meetup or parent night out in your area? What about sharing info at a resource booth at community events? Describe how you would like to be more involved.

Include my Family in the Camp Directory

Camp Directory would be distributed only to families who attended Family Camp to stay in touch beyond Camp. Would include Family members names, Kid ages, Parent Emails, Household Phone Number and City/State

Yes

No

What topics or information would you like to learn about or discuss at Family Camp?

Pre-Camp Survey

On a scale of 1-10, where 1 is strongly disagree and 10 is strongly agree please rate the following statements in regards to your family

I feel well connected to the T1D community.

I feel that people don’t understand what it is like to live with T1D.

I feel that connections to other people are important to living with T1D.

I feel equipped to deal with school and T1D.

I feel equipped to deal with whatever uncertainties T1D might bring to me and my family.

I have hope for my family’s future with T1D.

I feel overwhelmed by T1D and its impact on my family.

I feel that I have a well-developed T1D support system of family and friends.

Camp Policy Agreement and Waivers

Please read our ConnecT1D Family Camp Policy Agreement 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 person filling out this form

*

family camp registration (1).JPG

Payment Options

Registration Fee Structure:

Full Fare registration: the true cost per person attending camp.
Subsidized registration: is provided at one third the cost of camp (this option is available through generous grant and donor support) for those who would otherwise be unable to attend camp at the Full Fare fee. Proof of income must be submitted at time of application. Subsidy applications will be processed on a first come, first served basis.
Scholarships (provided by generous grant and donor support): Scholarship deposit (non-refundable): $50. Families with limited incomes and/or facing economic hardship, may apply for a scholarship to cover part or all of remaining fees. Proof of income must be submitted at time of application. Scholarship applications will be processed on a first come, first served basis. If deposit is a barrier to apply, may request a scholarship deposit waiver by contacting familycamp@connect1d.org.

Payment Due Date:

Full Fare and Subsidized Registration Fees must be paid at time of registration.
Scholarship Applicants will be reviewed and notified whether granted scholarship support on a rolling basis. Remaining balance is due within two weeks of notification.

Registration Pathway

*

Choose registration rate that matches your family's ability to pay

Full Fare Registration ($300/adult; $200/child 3-12; 0-2 $125)

Subsidized Registration ($105/adult; $85/child 3-12; 0-2 FREE)

Apply for a Scholarship $50 deposit (then 25%-75% off subsidized cost)

Full Fare Registration *	Quantity
$300 - Adult Registration
$200 - Child 3-12 (includes t-shirt)
$125 - Child 0-2 (includes t-shirt)

Subsidy Application

To apply for subsidy consideration, please select from options below, list family size, annual income, upload proof of income (1st page of 2017 tax return preferred; pay stub ok), and note any special considerations for your application such as recent reductions of family income due to loss of employment, multiple children with T1D or other chronic disorders, high medical costs due to T1D. Applicants will be considered on a rolling basis as they are submitted and we will notify you as quickly as possible..

Subsidized Registration *	Quantity
$105 - Subsidized Adult Registration
$85 - Subsidized Child (3-12yo) Registration (includes t-shirt)
$0 - Subsidized Child (0-2yo) Registration (includes t-shirt)

Household Size

Household Annual Income

Subsidy Request Notes

Upload Proof of Income

*

Most recent paystub or household 2016 tax documents

Scholarship Application

To apply for scholarship consideration, please select % of subsidized cost requesting, list family size, annual income, upload proof of income (1st page of 2018 tax return preferred; pay stub ok), and note any special considerations for your application such as recent reductions of family income due to loss of employment, multiple children with T1D or other chronic disorders, high medical costs due to T1D. Applicants will be considered on a rolling basis as they are submitted and we will notify you as quickly as possible.

Household Size

Household Annual Income

Scholarship Request Notes

Upload Proof of Income

*

Most recent paystub or household 2016 tax documents

Amount *	Quantity
$50 - Hold my spot: scholarship application deposit (due at registration)

Scholarship Level Requested (% of subsidized cost needed)

Please Note: Any remaining balance (of subsidized cost) must be paid by due by Sept 3, 2019.

Family Camp Shirts

All campers (ages 0-12) and volunteers will receive complimentary t-shirts.

Additional t-shirts and hooded sweatshirts are available for purchase through the following link.

Sweatshirt & T-shirt Order Form (will open in a new window)

Camp Registration is NOT complete until the form is submitted through the button below and payment is processed.

fam camp sweatshirt.jpg