KIS Program Request Form
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 shortly.
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? *
School Name: *
Your answer
School Phone Number: *
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: *
If you selected "other", please specify in detail:
Your answer
How important do you feel educating students and staff about diabetes is on a scale of 1 to 10? *
Least Important
Most Important
Approximate # of students in your school:
Your answer
Are there any specific issues you would like to be targeted during the speech?
Your answer
Is there anything else you would like to tell us?
Your answer
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