• Image field 685
  • Image field 865
  • Is this your first time attending a Touched by Type 1 Community Connections event?*
  • Format: (000) 000-0000.
  • Birthdate*
     - -
  • Languages Spoken*

  • Address

  • Which of the following describe you? Check all that apply.*
  • Image field 599
  • Diagnosis Date*
     - -
  • Current glucose monitoring*
  • Current insulin management*
  • Current mild hypoglycemia treatment*
  • Current hypoglycemia prescriptions*
  • Image field 677
  • Dietary restrictions (check all that apply)*
  • 0/100
  • Ethnicity (check all that apply)*
  • Do you need register an additional attendee? (Adult or Child)*
  • Image field 407
  • Image field 859
  • ▪ Is this their first time attending a Touched by Type 1 Community Connections event?*
  • ▪ Birthdate*
     - -
  • ▪ Languages Spoken*
  • ▪ Which of the following describe this attendee? (Check all that apply)*
  • ▪ Ethnicity (check all that apply)*
  • Image field 593
  • ▪ Diagnosis Date*
     - -
  • ▪ Current glucose monitoring*
  • ▪ Current insulin management*
  • ▪ Current mild hypoglycemia treatment*
  • ▪ Current hypoglycemia prescriptions*
  • Image field 678
  • ▪ Dietary Restrictions- please check all that apply*
  • ▪ Do you need register an additional attendee? (Adult or Child)*
  • Image field 827
  • Image field 860
  • ◦ Is this their first time attending a Touched by Type 1 Community Connections event?*
  • ◦ Birthdate*
     - -
  • ◦ Languages Spoken*
  • ◦ Which of the following describe this attendee? (Check all that apply)*
  • ◦ Ethnicity (check all that apply)*
  • Image field 759
  • ◦ Diagnosis Date*
     - -
  • ◦ Current glucose monitoring*
  • ◦ Current insulin management*
  • ◦ Current mild hypoglycemia treatment*
  • ◦ Current hypoglycemia prescriptions*
  • Image field 765
  • ◦ Dietary Restrictions- please check all that apply*
  • ◦ Do you need register an additional attendee? (Adult or Child)*
  • Image field 828
  • Image field 861
  • ◊ Is this their first time attending a Touched by Type 1 Community Connections event?*
  • ◊ Birthdate*
     - -
  • ◊ Languages Spoken*
  • ◊ Which of the following describe this attendee? (Check all that apply)*
  • ◊ Ethnicity (check all that apply)*
  • Image field 778
  • ◊ Diagnosis Date*
     - -
  • ◊ Current glucose monitoring*
  • ◊ Current insulin management*
  • ◊ Current mild hypoglycemia treatment*
  • ◊ Current hypoglycemia prescriptions*
  • Image field 784
  • ◊ Dietary Restrictions- please check all that apply*
  • ◊ Do you need register an additional attendee? (Adult or Child)*
  • Image field 829
  • Image field 862
  • ♦ Is this their first time attending a Touched by Type 1 Community Connections event?*
  • ♦ Birthdate*
     - -
  • ♦ Languages Spoken*
  • ♦ Which of the following describe this attendee? (Check all that apply)*
  • ♦ Ethnicity (check all that apply)*
  • Image field 797
  • ♦ Diagnosis Date*
     - -
  • ♦ Current glucose monitoring*
  • ♦ Current insulin management*
  • ♦ Current mild hypoglycemia treatment*
  • ♦ Current hypoglycemia prescriptions*
  • Image field 803
  • ♦ Dietary Restrictions- please check all that apply*
  • ♦ Do you need register an additional attendee? (Adult or Child)*
  • Image field 830
  • Image field 863
  • ☼ Is this their first time attending a Touched by Type 1 Community Connections event?*
  • ☼ Birthdate*
     - -
  • ☼ Languages Spoken*
  • ☼ Which of the following describe this attendee? (Check all that apply)*
  • ☼ Ethnicity (check all that apply)*
  • Image field 816
  • ☼ Diagnosis Date*
     - -
  • ☼ Current glucose monitoring*
  • ☼ Current insulin management*
  • ☼ Current mild hypoglycemia treatment*
  • ☼ Current hypoglycemia prescriptions*
  • Image field 822
  • ☼ Dietary Restrictions- please check all that apply*
  • ☼ Do you need register an additional attendee? (Adult or Child)*
  • Image field 831
  • Image field 864
  • ► Is this their first time attending a Touched by Type 1 Community Connections event?*
  • ► Birthdate*
     - -
  • ► Languages Spoken*
  • ► Which of the following describe this attendee? (Check all that apply)*
  • ► Ethnicity (check all that apply)*
  • Image field 839
  • ► Diagnosis Date*
     - -
  • ► Current glucose monitoring*
  • ► Current insulin management*
  • ► Current mild hypoglycemia treatment*
  • ► Current hypoglycemia prescriptions*
  • Image field 845
  • ► Dietary Restrictions- please check all that apply*
  • Image field 684

  • The following questions help us keep our programs and events free for participants and better understand, reach, and serve the Type 1 diabetes community.

  • How did you first hear about this event?*
  • Image field 681
  • Image field 668
  • Is your healthcare provider affiliated with a hospital network?*
  • Image field 670
  • Image field 669
  • Image field 673
  • Image field 674
  • Image field 635
    • Photo and Video Release 

    • Photo and Video Release
      I grant permission to Touched by Type 1, its partners, and event sponsors to photograph, record, and/or film me and any minor for whom I am registering during the event. I understand that these images or recordings may be used by Touched by Type 1 for educational, promotional, marketing, or fundraising purposes, including use on websites, social media, printed materials, and other media platforms, without compensation.

    • Release of Liability 

    • Assumption of Risk and Release of Liability
      Participation in this event is voluntary. I understand that there may be inherent risks associated with participation in community events and activities. I voluntarily assume all risks associated with my participation and the participation of any minor for whom I am registering.

      By completing registration and signing below, I acknowledge that I have read, understand, and agree to this Participant Waiver and Release of Liability.

    •  
    • I consent to sharing my registration information (specifically, my name and email address) with Touched By Type 1’s trusted partners and sponsors, like Tandem Diabetes Care, Inc. so that I can receive product-related follow-up and informational emails.*
    • I agree to receive occasional automated event related marketing text messages from Touched by Type 1 at the phone number provided. Consent is not a condition to register. Msg & data rates may apply.*
    • Format: +10000000000.
    • Marketing Consent - By submitting this form I agree to receive email communications from Touched by Type 1. I understand I can unsubscribe at any time using the link in any email.
    • Form Language*
  • Should be Empty: