Community Connections | Men's Paintball

Event Tag

Event Date

Date

Registration Type

Is this your first Touched by Type 1 event?*

YesNo

First Name*

Last Name*

Middle Name / Suffix (optional)

E-mail*

example@example.com

Phone Number*

Please enter a valid phone number.

Birthdate*

You must be 15 or older to attend

Languages Spoken*

EnglishSpanishOther

Participation

I will be playing paintballI will be accompanying someone as a spectator

Address

Unit / Suite

City

State

Postal code

Ethnicity - Please check all that apply*

Which of the following best describe you ? Select all that apply.*

Person with type 1 diabetesCaregiver to someone with type 1 diabetesSibling of a person with type 1 diabetesChild of a person with diabetesFriend or other relative of a person with type 1 diabetesHealth Care ProviderWork in the Type 1 Diabetes industry

Diagnosis Date*

Date

1. Dietary restrictions- please check all that apply

1. Please specify additional dietary restrictions below

0/100

Register another guest?*

YesNo