Emily's Hope 2015 Picnic Registration

Name of Type 1 Diabetic Child:

Age of child:

Name of Parent(s):

Total Number of attendees:

Email where we can contact you*:

Please provide any message or question
you have about this year's event:
* To our picnic attendees, this is run as a private event. We do not
share or distribute any email information with anyone, ever!