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Diabuddies School Tour Request Form
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* Indicates required question
Please fill out as much information as you can, so we are able to accommodate your request as efficiently as possible. You will be contacted by our staff when scheduling begins.
First Name
*
Your answer
Last Name
*
Your answer
Phone - Primary
*
Your answer
Email
*
Your answer
Name of Student(s) with T1D:
Your answer
Grade of Student(s) with diabetes:
Your answer
Which of our programs are you looking for?
*
Diabuddies Classroom/Online Presentation
Assistance developing your Care Plan
Staff Workshop including Baqsimi Training
School Name:
*
Your answer
School Phone Number:
*
Your answer
School Email Address
*
Your answer
School Address:
*
Your answer
School Board:
*
Your answer
Teacher's or Principal's Name:
*
Your answer
How many other students are known with T1D at your school?
*
Your answer
This request form is being filled by:
*
Choose
Parent/ Caregiver
Teacher
School Administrator
Other
If you selected "other", please specify in detail:
Your answer
Approximate # of students in your school (or class if requesting a classroom or online presentation)
Your answer
Are there any specific issues you would like to be targeted during the presentation?
Your answer
Is there anything else you would like to tell us?
Your answer
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