Full Name:
Date of Birth:
Date Diagnosed:
Parent(s) Name(s):
Home Address (incl. Postcode):
Mobile Telephone:
Personal Email Address:
Name & DOB of Sibling(s):
Insulin Pen or Pump Name:
Type of Insulin(s):
Test Strips/Lancets:
Other Equipment:
I confirm that I give permission for the HEY Kids Type One Diabetes Children, Young Adults and Family Support Group to store my child’s/family details and may use my child’s medical information...
I give HEY Kids the right to use my and my child’s image in the photographs...
Full Name (Printed):
Date:
