Walk to Cure Diabetes, online registration

Please complete the form below to register online. All fields marked with * are mandatory and MUST be completed.

Walk/Run Details

Please select the walk/run you are talking part in:*

Your Details

Title:*

Firstname:*

Surname:*

Address:*

Town:*

County:*

Postcode:*

Home phone:

(STD Code)

Work phone:

(STD Code)

E-mail Address:

I am interested in diabetes because:

JDRF will hold the information about your interest in diabetes on our database. It will not be used externally. If you do not want these details to be used in this way please tick the box.

Family Details

Please provide names of any other family members living at the same address who are also participating. If they are under 18 please provide their date of birth.

Will you be participating as part of a team?*

Yes
No (I'm participating as an individual).

Team Details

Team Category:*

Organisation:

Team name:

I am the team captain Yes No

Captain's firstname:

Captain's surname:

Privacy & Other Information

Any information you provide is covered by the 1998 Data Protection Act.

How did you hear about us:

Other - please specify:

I am happy for JDRF to contact me by e-mail

JDRF may wish to contact you again to provide you with other activities and services. Please tell us if and how you would prefer to be contacted:

Juvenile Diabetes

Walk to Cure Diabetes, online registration