Rockland Town Hall | May 6 @ 6 p.m. | Town of Ramapo Senior Center

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* 1. We invite you to join us at the Rockland Town Hall.

Please RSVP with your name, city, email and preferred phone number.

Name

City/Town

Email Address

Phone Number

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* 2. Are you bringing any guests? Please list their name and age (if under 18).

Name and age:

Name and age:

Name and age:

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* 3. What is your connection to type 1 diabetes (T1D)?

I have T1D

My child/children have T1D

My spouse has T1D

Another family member has T1D

My friend has T1D

My colleague has T1D

I have no connection to T1D

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* 4. Rank the following learning opportunities/events in order of importance to you. (1 is least important; 5 is most important)

	1	2	3	4	5
Research Update	Research Update 1	Research Update 2	Research Update 3	Research Update 4	Research Update 5
Adult Networking/Support Group	Adult Networking/Support Group 1	Adult Networking/Support Group 2	Adult Networking/Support Group 3	Adult Networking/Support Group 4	Adult Networking/Support Group 5
Child and Adult Support Group	Child and Adult Support Group 1	Child and Adult Support Group 2	Child and Adult Support Group 3	Child and Adult Support Group 4	Child and Adult Support Group 5
Safe at School/504 Training	Safe at School/504 Training 1	Safe at School/504 Training 2	Safe at School/504 Training 3	Safe at School/504 Training 4	Safe at School/504 Training 5
Taking T1D to College	Taking T1D to College 1	Taking T1D to College 2	Taking T1D to College 3	Taking T1D to College 4	Taking T1D to College 5
Fundraising Event	Fundraising Event 1	Fundraising Event 2	Fundraising Event 3	Fundraising Event 4	Fundraising Event 5
Youth Meetup Event	Youth Meetup Event 1	Youth Meetup Event 2	Youth Meetup Event 3	Youth Meetup Event 4	Youth Meetup Event 5

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* 5. Please share any topic suggestions or comments for the Rockland Town Hall.