Language
  • English (US)
  • Español
  • Event Date
     - -
  • Image field 331
  • Image field 333

  • The spring dance program is open to children ages 5 - 17 who have been diagnosed with Type 1 Diabetes.

     

    Note: If you have mutiple participants, you will need to complete a seperate form for each.

  • Image field 361
  • Please select the appropriate class:*

  • Please note: Class placement is mainly determined by age, however for ages 11-13 we may adjust class assignment based on other considerations.

  • Participation Type
  • Does the participant plan to attend any in-person classes?*
  • Participant's Birthdate*
     - -
  • Participant's languages Spoken*
  • Participant's ethnicity - Please check all that apply*
  • Please list any additional connection the participant has to type 1 diabetes? (Select all that apply.)
  • Participant's Diagnosis Date*
     - -
  • Image field 335
  • Is this the participants first time joining a Touched by Type 1 dance program?*
  • Format: (000) 000-0000.
  • Contact Birthdate*
     - -

  • Address

  • Image field 336
  • Your languages Spoken*
  • Which of the following best describe you (parent/guardian)? Select all that apply.*
  • Your diagnosis date*
     - -
  • Would you like to add another emergency contact?*
  • Image field 340
  • Format: (000) 000-0000.
  • ◊ Relation to participant:*
  • ◊ Your languages Spoken*
  • Image field 367
  • Which of the following best describe you (parent/guardian)? Select all that apply.*
  • Your diagnosis date*
     - -
  • Image field 337
  • How did you hear about this event?*
  • Is your healthcare provider affiliated with a hospital network?*

  • Your privacy matters to us. Touched by Type 1 will never sell, share, or give your personal information to anyone outside our organization.

    You may receive emails from us with updates about our programs and resources. These messages may occasionally include information about our partners - but all communication will always come directly from Touched by Type 1.

    All information you provide is stored securely and used only by our team.
    By submitting this form, you agree to receive emails from Touched by Type 1.

    You can unsubscribe at any time.

  • Consent to contact & store information
  • Would you like to receive text message event reminders from Touched By Type 1?
  • Should be Empty: