JUVENILE DIABETES RESEARCH FOUNDATION (JDRF)
Tidewater Chapter New Family Registration

Date: ___________________
Name of child with diabetes: _____________________________________
Date of Birth: ________ Date diagnosed _________ Male___ Female___
Home Address:________________________________________________
City, State, Zip Code: ___________________________________________
Email address: ________________________________________________

Mother’s name: ____________________ Mother’s home #:______________
Mother’s employer: __________________ work/cell phone #:_____________

Father’s name: _____________________ Father’s home #:______________
Father’s employer: __________________ work/cell phone #:_____________

Siblings (names & ages):_________________________________________
_____________________________________________________________
Hospital/Endocrinologist affiliation: _________________________________
School: ______________________________________________________
Grade: _______ Extra Curricular Activities: __________________________

Would you like to receive the Tidewater Chapter Discoveries quarterly Newsletter?  ___   (Y or N)

FAMILY CONNECTIONS /SUPPORT GROUPS

Would you and/or your family members attend meetings for:
Adults with type 1 ___ Yes ___ No
Parents Only ___ Yes ___ No
Families (Parents & children) ___ Yes ___ No
Mix of Parent-Only & family meetings ___ Yes ___ No
Teens ___ Yes ___ No
How often? ___ Monthly ___ Bi-Monthly ___ Quarterly
Preferred day & time for meeting: _________________________________
Would you be willing to host a Parent Coffee or arrange a venue? ___ Yes ___ No
Would you help coordinate a support group in your area: ___ Yes ___ No
What topics and types of guest speakers would you find of interest or helpful?
__________________________________________________________
__________________________________________________________
__________________________________________________________

BABY SITTING RESOURCES
Would you use a resource list of baby sitters? ___ Yes ___ No
Do you have teens or other family members who would baby sit for children with
Type 1 diabetes? ___ Yes ___ No

MENTORING PROGRAM
Would you like to have the opportunity to speak with another parent who lives in
your community or has a child of the same age as yours? ___ Yes ___ No
Would YOU be interested in becoming a mentor to other newly diagnosed families?
___ Yes ___ No

VOLUNTEER OPPORTUNITIES (CHECK ALL THAT INTEREST YOU)
___ Bag of Hope/Teen Pack Program (for newly diagnosed children & teens)
___ Mentoring Program (partnering parents of newly diagnosed with parents of
            similar age child/or geographic location)
___ Support Group Coordination
___ Family Event Planning
___ Office/Clerical (assist with mailings, etc.)
___ School Programs (Kids Walk to Cure Diabetes, education programs, 504       plans)
___ Advocacy (government relations, public speaking, media relations)
___ Walk to Cure Diabetes Team
___ Gala Volunteer
___ Sponsor a Fund Raising and/or Awareness Event

In what ways would you like JDRF to help you or other families affected by
Type 1 diabetes?

Are there ways YOU might be willing and able to help JDRF and families living with type 1?

Please share with us any other suggestions you may have for us.

  Please email to tidewater@jdrf.org or fax to the JDRF Tidewater Office at 757-445-6696