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Lets get you registered!
Important Note: For this event children and teens may be dropped off for the duration of the event. We still require that an adult register below in order to have a contact on file for the child/teen. If you plan to drop off the child/teen just indicate that in the next section.
Please indicate whether you'll be staying for the event or dropping off a child/teen.
I will be staying
I will be dropping off a child/teen
Please be aware that you will need to be present to check your child/teen into the party. For their safety we ask that you escort them into the studio and check them in.
1. Your First Name
*
1. Middle Name (optional)
1. Your Last Name
*
1. Your E-mail
*
example@example.com
1. Phone Number
*
Please enter a valid phone number.
1. Birthdate
*
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Month
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Day
Year
Date
Address
Address
Unit / Suite
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Please Select
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Tell us about yourself!
1. Languages Spoken
*
English
Spanish
Other
1. Other Language
Would you like to receive text message event reminders from Touched By Type 1?
Yes
No
1. Tell us about yourself
*
Person with type 1 diabetes
Caregiver to someone with type 1 diabetes
Sibling of a person with type 1 diabetes
Child of a person with diabetes
Friend or other relative of a person with type 1 diabetes
Health Care Provider
Work in the Type 1 Diabetes industry
1. Diagnosis Date
*
-
Month
-
Day
Year
Date
1. Dietary restrictions- please check all that apply
*
None
Gluten
Dairy
Egg
Nut
Soy
Shellfish
Vegan
Vegetarian
Other
1. Please specify additional dietary restrictions below
0/100
How many guests will be in your party? Only include guests who will be staying.
*
Please continue to add each guest in your party.
It's important we have information for each person in your party to best accommodate your group for this event.
1.. Would you like to add another person?
*
Yes
No
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Additional Guest
2. First Name
*
Guest 2
2. Middle Name (Optional)
2. Last Name
*
Guest 2
2. Birthdate
*
-
Month
-
Day
Year
Date
2. Languages Spoken
*
English
Spanish
Other
2. Tell us about yourself
*
Person with type 1 diabetes
Caregiver to someone with type 1 diabetes
Sibling of a person with type 1 diabetes
Friend or other relative of a person with type 1 diabetes
Health Care Provider
Work in the Diabetes industry
2. Diagnosis Date
*
-
Month
-
Day
Year
Date
2. Dietary Restrictions- please check all that apply
*
None
Gluten
Dairy
Egg
Nut
Soy
Shellfish
Other
2. Please specify additional dietary restrictions below
2. Would you like to add another person?
*
Yes
No
Back
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Additional Guest
3. First Name
*
3. Middle Name (Optional)
3. Last Name
*
3. Birthdate
*
-
Month
-
Day
Year
3. Languages Spoken
*
English
Spanish
Other
3. Tell us about yourself
*
Person with type 1 diabetes
Caregiver to someone with type 1 diabetes
Sibling of a person with type 1 diabetes
Friend or other relative of a person with type 1 diabetes
Health Care Provider
Work in the Diabetes industry
3. Diagnosis Date
*
-
Month
-
Day
Year
3. Dietary Restrictions- please check all that apply
*
None
Gluten
Dairy
Egg
Nut
Soy
Shellfish
Other
3. Please specify additional dietary restrictions below
3. Would you like to add another person?
*
Yes
No
Back
Next
Additional Guest
4. First Name
*
4. Middle Name (Optional)
4. Last Name
*
4. Birthdate
*
-
Month
-
Day
Year
4. Languages Spoken
*
English
Spanish
Other
4. Tell us about yourself
*
Person with type 1 diabetes
Caregiver to someone with type 1 diabetes
Sibling of a person with type 1 diabetes
Friend or other relative of a person with type 1 diabetes
Health Care Provider
Work in the Diabetes industry
4. Diagnosis Date
*
-
Month
-
Day
Year
4. Dietary Restrictions- please check all that apply
*
None
Gluten
Dairy
Egg
Nut
Soy
Shellfish
Other
Other
4. Please specify additional dietary restrictions below
4. Would you like to add another person?
*
Yes
No
Back
Next
Additional Guest
5. First Name
*
5. Middle Name (Optional)
5. Last Name
*
5. Birthdate
*
-
Month
-
Day
Year
5. Languages Spoken
*
English
Spanish
Other
5. Tell us about yourself
*
Person with type 1 diabetes
Caregiver to someone with type 1 diabetes
Sibling of a person with type 1 diabetes
Friend or other relative of a person with type 1 diabetes
Health Care Provider
Work in the Diabetes industry
5. Diagnosis Date
*
-
Month
-
Day
Year
5. Dietary Restrictions- please check all that apply
*
None
Gluten
Dairy
Egg
Nut
Soy
Shellfish
Other
5. Please specify additional dietary restrictions below
5. Would you like to add another person?
*
Yes
No
Back
Next
Additional Guest
6. First Name
*
6. Middle Name (Optional)
6. Last Name
*
6. Birthdate
*
-
Month
-
Day
Year
6. Languages Spoken
*
English
Spanish
Other
6. Tell us about yourself
*
Person with type 1 diabetes
Caregiver to someone with type 1 diabetes
Sibling of a person with type 1 diabetes
Friend or other relative of a person with type 1 diabetes
Health Care Provider
Work in the Diabetes industry
6. Diagnosis Date
*
-
Month
-
Day
Year
6. Dietary Restrictions- please check all that apply
*
None
Gluten
Dairy
Egg
Nut
Soy
Shellfish
Other
6. Please specify additional dietary restrictions below
6. Would you like to add another person?
*
Yes
No
Back
Next
Additional Guest
7. First Name
*
7. Middle Name (Optional)
7. Last Name
*
7. Birthdate
*
-
Month
-
Day
Year
7. Languages Spoken
*
English
Spanish
Other
7. Tell us about yourself
*
Person with type 1 diabetes
Caregiver to someone with type 1 diabetes
Sibling of a person with type 1 diabetes
Friend or other relative of a person with type 1 diabetes
Health Care Provider
Work in the Diabetes industry
7. Diagnosis Date
*
-
Month
-
Day
Year
7. Dietary Restrictions - please check all that apply
*
None
Gluten
Dairy
Egg
Nut
Soy
Shellfish
Other
7. Please specify additional dietary restrictions below
7. Would you like to add another person?
*
Yes
No
Back
Next
Additional Guest
8. First Name
*
8. Middle Name (Optional)
8. Last Name
*
8. Birthdate
*
-
Month
-
Day
Year
8. Languages Spoken
*
English
Spanish
Other
8. Tell us about yourself
*
Person with type 1 diabetes
Caregiver to someone with type 1 diabetes
Sibling of a person with type 1 diabetes
Friend or other relative of a person with type 1 diabetes
Health Care Provider
Work in the Diabetes industry
8. Diagnosis Date
*
-
Month
-
Day
Year
8. Dietary Restrictions- please check all that apply
*
None
Gluten
Dairy
Egg
Nut
Soy
Shellfish
Other
8. Please specify additional dietary restrictions below
8. Would you like to add another person?
*
Yes
No
Back
Next
Additional Guest
9. First Name
*
9. Middle Name (Optional)
9. Last Name
*
9. Birthdate
*
-
Month
-
Day
Year
9. Languages Spoken
*
English
Spanish
Other
9. Tell us about yourself
*
Person with type 1 diabetes
Caregiver to someone with type 1 diabetes
Sibling of a person with type 1 diabetes
Friend or other relative of a person with type 1 diabetes
Health Care Provider
Work in the Diabetes industry
9. Diagnosis Date
*
-
Month
-
Day
Year
9. Dietary Restrictions- please check all that apply
*
None
Gluten
Dairy
Egg
Nut
Soy
Shellfish
Other
9. Please specify additional dietary restrictions below
9. Would you like to add another person?
*
Yes
No
Back
Next
Additional Guest
10. First Name
*
10. Middle Name (Optional)
10. Last Name
*
10. Birthdate
*
-
Month
-
Day
Year
10. Languages Spoken
*
English
Spanish
Other
10. Tell us about yourself
*
Person with type 1 diabetes
Caregiver to someone with type 1 diabetes
Sibling of a person with type 1 diabetes
Friend or other relative of a person with type 1 diabetes
Health Care Provider
Work in the Diabetes industry
10. Diagnosis Date
*
-
Month
-
Day
Year
10. Dietary Restrictions- please check all that apply
*
None
Gluten
Dairy
Egg
Nut
Soy
Shellfish
Other
10. Please specify additional dietary restrictions below
Back
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Current Date
1. Age Mirror
2. Age Mirror
3. Age Mirror
4. Age Mirror
5. Age Mirror
6. Age Mirror
7. Age Mirror
8. Age Mirror
9. Age Mirror
10. Age Mirror
Event Tag
Please Select
Coffee T1D and Me
Walk Kick Off
Bowling
Steps To A Cure
Golfing Fore Diabetes
Topgolf
Couples Night
Skate Night
Ladies Night
Family Picnic
Dance Program
Orlando Pride Game
Annual Conference
Halloween Party
DFDiabetes
Holiday Party
1. Dropped off status
Please Select
Drop Off
With A Party
Emergency Contact
2. Dropped off status
Please Select
Drop Off
With A Party
Emergency Contact
3. Dropped off status
Please Select
Drop Off
With A Party
Emergency Contact
4. Dropped off status
Please Select
Drop Off
With A Party
Emergency Contact
5. Dropped off status
Please Select
Drop Off
With A Party
6. Dropped off status
Please Select
Drop Off
With A Party
7. Dropped off status
Please Select
Drop Off
With A Party
8. Dropped off status
Please Select
Drop Off
With A Party
Emergency Contact
9. Dropped off status
Please Select
Drop Off
With A Party
10. Dropped off status
Please Select
Drop Off
With A Party
Emergency Contact
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How did you hear about this event?
Is this your first Touched by Type 1 event?
Yes
No
How did you hear about this event?
Social Media
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Friend or Family member
Healthcare Provider
At another healthcare event (Friends For Life, Breakthrough T1d, etc.)
Search Engine (Google, Yahoo, etc.)
Touched By Type 1 event , newsletter, D-Box
At School
Other
Healthcare provider's name
We would love to thank them for spreading the word!
Type of healthcare provider
Please Select
Endocrinologist / Endocrinology team
Primary Care Physician
Hospital / Clinic
Is your healthcare provider affiliated with a hospital network?
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Not sure
Which hospital or clinic?
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Advent Health
Orlando Health
Halifax
Nemours
Nicklaus Children's
Other
Memorial
Tampa General
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Facebook Support Group
Facebook Ad
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