Diabetic Youth Service Information Request

Request Information

If you would like to information regarding the programs of Diabetic Youth Services, Inc., please check the following boxes and complete the requested information.

NOTE: Your personal information entered here will not be sold or rented to any companies or organizations.

DON'T DELAY....Register online for youth and family camps!

It is recommended that families register online for camps.

If you would like to information regarding the programs of Diabetic Youth Services, Inc., please check the following boxes and complete the requested information.

NOTE: Your personal information entered here will not be sold or rented to any companies or organizations.

IF YOU ARE UNDER THE AGE OF 13, YOU ARE PROHIBITED FROM COMPLETING THIS FORM:
The information requested will be used to send requested information to the address provided. If under the age of 13, your parent or guardian must submit this information.

Name:
Email Address:
Phone number with area code
Camper's/child's First Name (if applicable)
Camper's/child's Last Name (if applicable)
Street Address
Unit/Apt Number
City
State
Zip Code
I am interested in the following:	Camp brochure Youth Session Traditional Family Camp Transition Family Camp Financial Assistance Teen Winter Camp (February 2009) Leadership / Counselor-in-Training (CIT) Volunteer Medical Staff Program Staff
I would also like to:	Be a possible volunteer. Assist in special events and fundraising opportunities. Update my contact information. Be removed from your mailings. Receive information about renting Camp Conrad-Chinnock.
Provide any other information regarding your request(s):

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