50% of survey complete.

Please fill out a separate attendee registration form for each person registered for the SWD Conference.

* 1. Attendee Information:

* 2. Attendee Age:

* 3. Birth Date:

* 4. Gender:

* 5. What type of diabetes do you have?

* 6. If you have diabetes, how many years have you had diabetes?

* 7. What type of insulin do you use?

* 8. What type of insulin delivery do you use?

* 9. Are you attending the conference as a friend or significant other of a person with diabetes?

* 10. If you are in school, what College or University do you attend?

* 11. What is your academic year?

* 12. If you are out of college, what do you do professionally?

* 13. Name of Emergency Contact:

* 14. Relationship to Emergency Contact:

* 15. Phone Number for Emergency Contact:

* 16. Do you have any special dietary needs? Please check all that apply.

* 17. Do you have any other allergies we should know about?

* 18. Do you use an Epi Pen?

* 19. Roommate Request: Who do you want to room with at the conference? (Make sure that person also suggests you.)

* 20. T shirt size:

* 21. What is your Twitter handle? (We want to follow you!)

* 22. What is your Facebook name? (We want to friend you!)

* 23. How many SWD conferences have you attended?

* 24. How did you hear about this conference?

* 25. What are your top 3 things you want to learn about?

* 26. Photos will be taken at the conference - please make sure the photographer knows if you do not want to be photographed. Please acknowledge that you have read this by checking YES if you would like to be in photographs and NO if you would like to not be in photographs.

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