JDRF Georgia Family Network

Last Name:

First Name:

Home Address:

City:

State:

Zip:

Phone:

E-Mail:

# of Attendee
eating lunch:

Other than diabetes, please list other dietary restrictions (allergies, vegetarian, etc.).
Please include the name of the individual with the restrictions:

Class Preferences

Please select one class from each time slot. For class descriptions or for more information, click here.

9:00am:
10:00am:
11:00am:

Family Members

Use the fields below to enter up to 5 other family members (Rising 6th graders through Adult) who will be participating in the classes. Childcare will be provided for your younger children (see Childcare).

Last Name:

First Name:

Class Preferences:

9:00am:
10:00am:
11:00am:

Last Name:

First Name:

Class Preferences:

9:00am:
10:00am:
11:00am:

Last Name:

First Name:

Class Preferences:

9:00am:
10:00am:
11:00am:

Last Name:

First Name:

Class Preferences:

9:00am:
10:00am:
11:00am:

Last Name:

First Name:

Class Preferences:

9:00am:
10:00am:
11:00am:

Childcare

Childcare will be provided for your children aged Infant to Rising 5th Grader. Please fill in their information below and specify t-shirt size if applicable (sizes start at youth small).

Last Name	First Name	Age	Grade (in Fall '08)	Has Diabetes?