Candidate information

First name

Last name

Mr. or Ms.
Mr.Ms.

Address

City

Province

Postal code

Email address

Phone principal

Phone other

Profession

Company

I am
Diabetic adultDiabetic children (under 18)Parent of diabetic children (type 1)Parent of diabetic children (type 2)Legal tutor of diabetic childrenMember of diabetic children’s familyFriendVolunteerEmployee of the Foundation or Camp CarowanisOther

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.
Mr.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
FémininMasculin

Hospital

Doctor’s name

Date of birth (AAAA-MM-JJ)

Date of diagnose (AAAA-MM-JJ)

Spoken language(s)

Home
Live with both parentsShared parentingLive with motherLive with fatherOther

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.