Children's Congress Application

Application Instructions

1. Each of the fields below with an asterisk (*) next to it is a required field.  You will not be able to submit your application if the information is not provided for each of these fields. 
2. Please note that you cannot fill out a portion of the application and save your answers.  So, you must fill out the form completely and submit it in one step.
3. When you are finished with your application, simply hit the 'Submit' button at the bottom of the form.
4. Please note that, once you submit your application, you will not be able to retrieve it to edit any of your answers. 
5. After you submit your application, you will receive a confirmation email from JDRF.

Remember, to submit an application for consideration, the applicant MUST:

1. Have type 1 diabetes
2. Be between the ages of 4 and 17 on June 20, 2011
3. Have never been a Children's Congress delegate before

The deadline for applications to be received by JDRF is 5pm EDT, Monday, October 4, 2010.

To download a hardcopy of the application and submit it through the mail, please click here.

To view a list of frequently asked questions about the application process, please click here.

* denotes required fields.

* Legal First Name of Child:

Legal Middle Name of Child:

* Legal Last Name of Child:

* Gender:  Male  Female

* Birth date: (mm/dd/yyyy)

Age on June 20, 2011:

* Legal First Name of Parent/Guardian:

* Legal Last Name of Parent/Guardian:

* Address 1:

Address 2:

* City:

* State: =choose your state= Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming

* Zip Code:

* Home Phone:

Work Phone:   Extension:

Cell Phone of Parent:

Cell Phone of Child:

* Parent's Email Address:

Child's Email Address: (only if different from parent's)

JDRF Chapter Information

* Local JDRF Chapter/Branch: =Choose A Branch= Akron/Canton Branch Alabama Chapter Austin Chapter Bakersfield Branch Baton Rouge Branch Capitol Chapter Central Florida Chapter Central Jersey Chapter Central New York Chapter Central Oklahoma Chapter Central Pennsylvania Chapter Central Virginia Chapter Charlotte Chapter Cheyenne Branch Colorado Springs Branch Delaware Branch Desert Southwest Chapter East Central Pennsylvania East Tennessee Branch Eastern Iowa Branch Eastern Pennsylvania Chapter El Paso Council Fairfield County Chapter Florida Suncoast Chapter Fresno Branch Georgia Chapter Gr. Palm Beach County Chapter Greater Arkansas Chapter Greater Bay Area Chapter Greater Blue Ridge Chapter Greater Cincinnati Chapter Greater Dallas Chapter Greater Dayton Chapter Greater Fort Worth/Arlington Chapter Greater Iowa/South Dakota Chapter Greater New Haven Chapter Hawaii Chapter Houston Gulf Coast Chapter Illinois Chapter Indiana State Chapter Inland Empire Chapter Inland Northwest Branch JDRF Northwest Chapter Kansas City Chapter Kentuckiana Chapter Laredo Office Lincoln Chapter Long Island Chapter Los Angeles Chapter Louisiana Chapter (New Orleans Branch) Maryland Chapter Metro Detroit & SE Michigan Chapter Metro Saint Louis/Greater MO Chapter Michigan Great Lakes West Chapter Mid-Jersey Chapter Mid-Ohio Chapter Middle Tennessee Chapter Minnesota/ North Dakota/ South Dakota Chapter Mississippi Chapter NENY/Gr. Adirondack Region Branch NENY/Hudson Valley Branch Nevada Chapter New England Chapter/Bay State New England/Northern New England (ME) New England/Northern New England (NH) New England/Rhode Island Branch New Mexico Branch New York Chapter North Central CT and Western MA North Florida Chapter North Louisiana Branch Northeast Ohio Chapter Northeast Wisconsin Chapter Northeastern NY/Capital Region Northern California Inland Chapter Northern Indiana Branch Northern NJ-Rockland County Chapter Northern Nevada Branch Northern New England Northwest Arkansas Branch Northwest Ohio Chapter Northwestern PA Branch Omaha Council Bluffs Chapter Orange County Chapter Oregon/SW WA Chapter Palmetto Chapter Panhandle Branch Piedmont Triad Chapter Rochester Chapter Rocky Mountain Chapter San Diego Chapter Seattle Guild Sioux Falls Council South Central Texas Chapter South Florida Chapter South Jersey Chapter South Sound Branch Southeastern WI Chapter Southern Arizona Branch Southwest Florida Council Tampa Bay Chapter Tidewater Chapter Triangle/Eastern NC Chapter Tulsa Green Country Chapter Utah Chapter West Tennessee Branch West Virginia Branch Westchester County Chapter Western Carolinas Chapter Western New York Chapter Western Pennsylvania Chapter Western Wisconsin Chapter
Don't know your local chapter or branch? Look Here (opens new window)

* Federal Representative: First Select Your State Above
Don't know who is your federal representative? Look Here (opens new window)

Additional Information

* Has child been a Children's Congress Delegate in the past? yes no

* Does the child have a sibling with type 1? yes no

* Age of Sibling: (as of 6/20/2011)

* Has any sibling ever attended as a delegate? yes no

* What Children's Congress event was attended?

* Have you applied to Children’s Congress in the past? yes no

* If so, which year(s)?

* Letter to Representative: Write your letter to your Representative to upload with your application. Be sure to put your name and address at the top of the letter. Please address your letter to “Dear Member of Congress.” The letter should not exceed three typed pages or 1,200 words. JDRF will not accept or consider any additional application materials, including CD’s, DVD’s, recommendation letters and other such items. We will copy your letter to your senators as well as your representative and therefore don’t need specific names.

Your letter MUST include the following topics:

• Your personal story about living with type 1 diabetes
• Why a cure for juvenile diabetes is important to you
• Why the U.S. Congress should support diabetes research issues to help find a cure for type 1 diabetes
• If applicable, what have you done to promote awareness of type 1 diabetes in your community
• Acceptable file formats are .doc, .docx, .pdf, odf, and .txt

* Upload an image of the child applying:
Picture must be headshot/passport quality

Children's Congress 2011 Questionnaire

(please provide three to four sentences on the following required questions)

* Your activities and hobbies:

* Your interests and aspirations:

* Your accomplishments:

* What you hope to accomplish as a delegate to Children's Congress:

Please review additional Children's Congress delegate responsibilities: As a 2011 Children’s Congress applicant and parent/guardian, we agree to the following if the applicant is selected as a delegate: • We will abide by the rules, conventions and terms of the JDRF Children’s Congress 2011 • We have not attended a past Children’s Congress as a delegate • We will participate in every event at Children’s Congress • We will participate in a 2012 Promise to Remember Me meeting in our home Congressional district • We know that the delegate’s name, photo, and story become the property of the JDRF and may be used in print, radio, television, Internet (with appropriate safeguards), and in any other appropriate media to promote JDRF’s mission and goal • We understand there may be discussion of the complications of diabetes during the JDRF Children’s Congress 2011 • We agree to complete all delegate assignments, including creating a delegate scrapbook, by the deadline assigned by JDRF • We understand that only one parent/guardian can attend the JDRF Children’s Congress 2011

* I agree to the above additional delegate responsibilities: yes no

* How did you hear about Children's Congress: JDRF website
Email from JDRF
JDRF chapter/chapter newsletter
Facebook
Twitter
Countdown magazine
Other
If Other, where?