Diabetes 123 Conference and Expo -- July 17-21, 2002
Registration Form
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Registration Fee
Early Registration (before April 1, 2002): $250
Regular Registration (April 1-July 1, 2002): $275
Late registration (after July 1, 2002): $300
Family Registration includes 2 adults and their accompanying children under age 18. Additional adults are $25 per person.
Family and Event Information (Please include every person attending)
| First Name |
Last Name |
If under
18, age
of child |
Family and
Friends Banquet
Adults $30
Child (3-11) $15
(Thursday night) |
Dining with
the Experts
Adult $30
Child $10
Teen Dance (12+) $10
(Friday night) |
CWDF Benefit
Universal Studios
Adult $40
Child (3-11) $30
(Saturday all day) |
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| Registration Fee (see above): |
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Extra t-shirts or tanks:
$10 each, mark sizes and quantity below |
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| Additional Tax Deductible Donation to the CWD Foundation: |
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T-Shirt or tank tops: Please enter quantity. Include one shirt for each person attending (ok to mix and match tanks and tees). Additional shirts may be purchased and are $10 each (see above). Shirts will not be available for sale at the conference. We highly recommend buying additional shirts, so you can wear a fresh shirt each day of the conference.
| T-shirts |
| Adult | __Small | __Med | __Large | __X Large | __XX Large |
| Child | __Small | __Med | __Large | |
Tank tops |
| Adult | __Small | __Med | __Large | __X Large | __XX Large |
| Child | __Small | __Med | __Large | |
Registration for all participants includes:
- Reception Wednesday evening
- Buffet breakfast Thursday and Friday
- Morning and afternoon snack breaks Thursday and Friday
- Hors d'oeuvres reception Friday afternoon
- Child care for children under age 9 while parents are in conference (please note that childcare is for full days only and pre-registration is required by dates specified on the childcare registration forms)
- Conference t-shirt or tank top
- Conference materials
Pump Sessions:
The pump sessions taught by John Walsh are by ticket only and are limited to 50 people per session. If you wish to attend a pump session, please indicate which session and the names of the people who will be attending.
Pumping
Session |
Names of Attendees |
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Friday |
Beginner
Pumping |
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Advanced
Pumping |
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Method of Payment:
| __ VISA |
__ Mastercard |
__ Check made payable to "Diabetes 123" |
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| Name as it appears on the card: |
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| Signature (required): |
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| Please mail your registration to: |
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Laura Billetdeaux
Events Coordinator
Diabetes123
319 E. Duncan
Manchester, MI 48158
Or fax your registration form to Laura Billetdeaux at 734-428-0106.
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Last Updated: Monday December 16, 2002 09:25:10
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