ConnecT1D · 2018 ConnecT1D Retreat Registration

A. Event Tickets

Promo Code

Ticket	Quantity
$250 - Adult Ticket

Discounted Volunteer Ticket	Quantity
$175 - Volunteer Ticket

Please add the below amount to my total as a donation to ConnecT1D programs.

$

B. Attendee Registration Details

Birthdate

*

(mm/dd/yyyy)

Name

*

First Name

Last Name

Gender

My Relationship to Type 1

*

I have T1D

I am a friend/family member of someone with T1D

T1D Diagnosis Date

(mm/dd/yyyy)

Phone

*

Email

*

Verify Email

*

Phone Type

Facebook Username

E-communications

Sign me up to receive more info about:

General ConnecT1D events/updates

Adult Social Group Meetups

Volunteer Opportunities

Dietary Restrictions (T1D participant)

Vegetarian

Vegan

Dairy Free

Gluten Free

Nut Allergy

Primary Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Other accommodations needed at event?

2B. Attendee #2 Registration

Guest #2

*

First Name

Last Name

Guest #2 Birthdate

*

(mm/dd/yyyy)

Guest #2 Gender

Guest #2 Email

*

Verify Email

*

My Relationship to Type 1

*

I have T1D

I am a friend/family member of someone with T1D

T1D Diagnosis Date

(mm/dd/yyyy)

Dietary Restrictions (Guest #2)

Vegetarian

Vegan

Dairy Free

Gluten Free

Nut Allergy

E-communications

Sign me up for more info on:

General ConnecT1D events/updates

T3/Partners of T1Ds topics

Adult Social Group Meetups

Volunteer Opportunities

Guest #2: Other accommodations needed at event?

C. Pre-Conference Questionaire

Tell us a little more about your Type 1 experience, so we can tailor the retreat to best serve you!

How did you hear about the Retreat?

*

Survey

Please respond with how much you either agree or disagree with regards to the following statements.

Statement 1

Feeling isolated affects the way I manage my diabetes.

Statement 2

Feeling shameful affects the way I manage my diabetes.

Statement 3

I have the knowledge and skills I need to manage my diabetes well.

Statement 4

I feel supported by others in the T1D community.

Statement 5

I feel informed and up to date about the latest T1D technology and research.

Statement 6

I am reluctant to let others know that I have T1D.

Statement 8

I have hope for a healthy life with T1D.

What is your biggest challenge living with diabetes?

What emotional/psychosocial topics would you most like to see addressed at the Retreat?

What research and/or technology topics would you most like to see covered at the Retreat?

Any other topics you'd like to see covered at the Retreat?

Thank you for your input!