Contacts

Chris Jarvis
chris@insulindependence.org

Peter Nerothin
peter@insulindependence.org

Seminar Regristration Form

Because there is limited seating capacity at the designated venue, seating demand will be very high. For this reason we ask that each person carefully considers their schedule before registering, with full intent on attending on April 25th. In filling out the form below, he or she gives Insulindependence volunteers permission to contact him or her in order to verify this intent.

I have read and acknowledged the above statement

I will only be attending the Benefit Ride (please skip first box of questions)

How many children will be attending?
How many adults will attend? (Up to 2)
Are you a health care professional?
Are you participating in the benefit ride?


Full Name
Address
City
State
Email
Daytime Phone
Evening Phone


Please provide the names of all those in your group, explaining briefly their relation to diabetes.


 


Name of Sponsored Cyclist
Hometown
Age  
Would you like to purchase a tee shirt for $12?
 

Name of Accompanying Cyclist
Hometown
Age  
Would you like to purchase a tee shirt for $12?
 

Name of Accompanying Cyclist
Hometown
Age  
Would you like to purchase a tee shirt for $12?
 


Special Circumstances / Comments


 


 

 
     
Insulindependence is a 501(c)3 non-profit organization