DIABETES DIPLOMAT APPLICATION 2005

Yes, I would like further information about the Diabetes Diplomat Program. DEADLINE TO RETURN IS FRIDAY JANUARY 14^TH, 2005 and you do not have to have diabetes to participate; you only have to want to make a difference for those who live with diabetes everyday. I would also like to learn about the exciting prizes and recognition by Community Leaders in store for the children.

CHECK ONE

_______ I am a school Club Coordinator, Nurse or Principal

_______ I am a Parent/Guardian of the child listed below

Name: ________________________________________________________________________

Address: _______________________________________________________________________________

Town: ________________________ Zip: ____________________________

Phone: ________________________________________________________

Child’s Name: __________________________________________________

Grade: _______________ School Name: ____________________________________________

School District: _________________________________________________________________

Parent/Guardian/School representative Signature: ___________________________________

Fax back to: 516.621.8501

Or mail to:

The Diabetes Research Institute Foundation

Diabetes Diplomat Program

45 Glen Cove Road

Greenvale, NY 11548

Official sponsors of the Diabetes Diplomat Program