ConnecT1D · 2017 ConnecT1D Teen Leadership Camp Registration

Teen Leadership Application

Include 2-3 paragraphs for each question before

What about the ConnecT1D Teen Leadership Camp appeals to you?

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What do you hope to get out of the ConnecT1D Teen Leadership Camp?

What does leadership mean to you as it relates to your diabetes?

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Contact Information

Camper Name

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First Name

Last Name

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Birthdate

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(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

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2nd Parent/Guardian Name

First Name

Last Name

Camper T-shirt Size

Dietary Restrictions

Vegetarian

Celiac

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

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(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.)

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I check my blood sugar overnight

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I am able to check my blood sugars overnight independently

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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

Registration Fees

Non-refundable Deposit: All campers registering are required to pay a $30 registration fee at time of registration

Registration Fee Structure:

Full Fare registration is the true cost per person attending camp.
Subsidized registration, allows campers who cannot afford full fare registration to register at a reduced fee (this options is available through generous grant and donor support)
Families facing economic hardship may apply for a scholarship to cover part or all of remaining fees. 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 and Subsized Registration Fees must be paid at time of registration.
Scholarship Applicants will be notified by June 30th whether granted scholarship support. Remaining balance is due July 15th.

Scholarship

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Limited need-based scholarships are available

I would like to apply for a scholarship to cover additional % of subsidized costs

Amount

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$600 - Full Price Teen Registration

$300 - Subsidized Teen Registration

$30 - Deposit if applying for Scholarship

Please add the below amount to my total as a donation to the ConnecT1D Teen Leadership Camp

$

Household Size

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Household Annual Income

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Upload Proof of Income

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Most recent paystub or household 2016 tax documents

Scholarship Request Notes

Scholarship Level Requested (% of subsidized cost)

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Amount

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$30 - Scholarship Applicant Registration Fee

Camp Policy Agreement and Waivers

Please read our ConnecT1D Teen Leadership Policy in entirety and accept below.

Policy & Waiver Agreement

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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

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ConnecT1D social media, newsletters, and involvement

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

I'd like an invitation to the ConnecT1D Teen Leadership Camp Facebook Group for Camp

Your username on Facebook

I'm interested in

Joining the ConnecT1D E-newsletter list

Volunteering at an event