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* 1. Full Name 

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* 2. E-mail Address

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* 3. Cell Phone

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* 4. Home Address

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* 5. Birthday

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* 6. T1D Connection:

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* 7. If T1D, when were you diagnosed? (please put age and date)

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* 8. Where & What do you do for work?

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* 9. What other JDRF events are you involved in?

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* 10. What type of socials would you like to see the YLC do?

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