Formfor10-4Camp3

Lions Diabetes Camp Registration

Family Camp in October 4-6, 2024

Patient's Name

required

Age of Patient

Sex/Gender

Male Female Other sexual orientation

Diabetes Type

Type I Type II Pre-Diabetes

Street Address

required

City

required

State

required

Zip

Endocrinologist

Food or Other Allergies

Parent/Guardian/Adult Patient Name

Email

Phone No. 1 (adult/guardian)

Phone No. 2 (adult/guardian)

Is this the patient's first time at camp?

Yes No

Patient's T-Shirt Size

Additional Family Members Attending

Cost of Camp Registration is $25.00 per family non-refundable. You will be asked to provide this $25.00 registration payment prior to receiving a confirmation from us.