2012 Registration Form

Parent Name: _________________________________________________________

Child Name: _____________________________________ Age: _____________

Clinic Time: 12:30 - 2:00 (9-14 year olds) _____

                   2:30 - 3:30 (4-8 year olds) _____

Address: ____________________________________________________________

City/State: __________________________________  Zip Code: ___________

Home Phone: _____________________________________________________

Cell Phone: _______________________________________________________

Email: ____________________________________________________________

(confirmation of registration will be sent here)

Child Allergies (snacks will be provided on site): ________________________

Please Enclose $30 check made payable to Juvenile Diabetes Research Foundation.  Registration will be on a first come first serve basis. 

Print out form and mail registration to:

Emma Perelman

1410 Squirrel Hill Ave.

Pittsburgh, PA 15217