Family Network Questionnaire

Your Name:

Mr. Mrs. Ms. Dr.

Address:

Phone:

()

day eve

E-Mail:

Area:

Central (e.g. La Jolla)

East County (e.g. El Cajon)

El Centro

South Bay (e.g. Chula Vista)

North County Inland (e.g. Escondido)

North County Coastal (e.g. Carlsbad)

Not Sure

Please Tell Us About Your Interests

I would like to be a:
Family Network Captain	Family Network Co-captain	Family Network Member

I am interested in:
Organizing an event	Hosting an event	Attending events
Support Meetings	Morning Coffees	Walking with other parents
Babysitting Sharing	Pool Parties	Other Social Family Gatherings
Hiking	Biking	Camping Trips
Going to the Beach	Other:

Updates:
I would like to receive email updates on family network events

Diabetes Connection (e.g. son, daughter, self, etc.)
Person with diabetes:
Male Female Age: Age of Diagnosis:

Juvenile Diabetes Research Foundation International