General details

Participant Name*
First name Surname
Membership Number
DI# - - - - - -
Date of Birth*
DD slash MM slash YYYY
Address*
Street Address Address Line 2 City Eircode Country
Parent(s)/ Guardian Name*
First name Surname
Parent(s)/ Guardian Mobile*
one
Parent(s)/ Guardian Email*
One
Activity Centre of Choice*
Part 2 - Participant's medical details
Method of insulin administration?*
- Injection
- Pump
Administer own insulin?*
- Yes
- No
Ability to change infusion set by self?*
- Yes
- No
Method of glucose checks?*
- Sensor
- Manual
Hospital you attend?*
Other medical conditions we need to be aware of? If so please explain.*
Any Allergies?*
Other Medical Issues & Dietary Needs*
Please confirm you are happy to be contacted by Diabetes Ireland by post/ phone/ email in relation to this event?*
- Yes
Please Note
Diabetes Ireland will confirm your place following receipt of your application form within 3 working days. Non-Members – Diabetes Ireland will contact the named parent/ guardian to take credit/ debit card payment of €25 securely by phone and confirm your teenager’s place within 3 working days following receipt of the application form. Consent forms and further information about the event, clothing requirements, meeting places, bus times etc routes will be sent to you nearer the event date.

Part 2 - Participant's medical details