Membership

To learn more about our activities, to receive our invitations and to stay up to date with the latest news, become a member of the Foundation. This is free and without obligation. Let’s keep in touch by filling in the online form below.

If you prefer to send your form by regular mail, please use this Membership Form.

    Candidate information

    First name

    Last name

    Mr. or Ms.

    Address

    City

    Province

    Postal code

    Email address

    Phone principal

    Phone other

    Profession

    Company

    I am

    If you are the parent or legal tutor of children with diabetes, fill the following sections:

    Partner information

    First name

    Last name

    Mr. or Ms.

    Address, if different than above

    City

    Province

    Postal code

    Email address

    Phone principal

    Phone other

    Profession

    Company

    Child information

    First name

    Last name

    Sex

    Hospital

    Doctor’s name

    Date of birth (AAAA-MM-JJ)

    Date of diagnose (AAAA-MM-JJ)

    Spoken language(s)

    Home

    This information will remain confidential.

    I support the cause of diabetic children and I want to make a donation

    I would like to be contacted to volunteer.

    I declare that the information provided above is accurate.