Page 1
Please provide all details for each person attending the event.
First name
Last name
Email address
State or territory
Please select...
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Phone number (so we can text you important info)
My T1D connection is...
Please select...
I have T1D
My child has T1D
My child and I have T1D
I'm a HCP
I’m a HCP and I have T1D
I'm a HCP and have a child with T1D
My grandchild has T1D
My partner has T1D
My relative has T1D
My sibling has T1D
My friend has T1D
Other
I do not have a connection
My dietary requirements (type 'none' if this doesn't apply)
T1D has been in my life for...
Please select...
12 months or less
1-3 years
3-5 years
5+ years
I'm a healthcare professional
I am attending the:
Please select...
Adult session
Parent/Carer session
Both
Page 2
Do you have additional adults attending with you?
Yes
No
Additional adult details
First name of additional adult (this email address MUST be different)
Last name of additional adult
Email address of additional adult (this must be different from the email address entered above)
T1D connection of additional adult...
Please select...
I have T1D
My child has T1D
My child and I have T1D
I'm a HCP
I’m a HCP and I have T1D
I'm a HCP and have a child with T1D
My grandchild has T1D
My partner has T1D
My relative has T1D
My sibling has T1D
My friend has T1D
Other
No connection
Dietary requirements of additional adult (type 'none' if this doesn't apply)
Page 3
Will you be bringing your child with T1D to the morning session?
Yes
No
Name of child with T1D
How old will your child be on 26 July 2026?
Dietary requirements of child with T1D. (Enter 'none' if this doesn't apply.)
Does your child with T1D have any other medical conditions we should be aware of? Please specify.
(Enter 'none' if this doesn't apply.)
This event will involve filming and photography of our attendees. Do you give permission for your child to be filmed and photographed?
Yes
No
If you have another child with T1D, please email us at info@BreakthroughT1D.org.au to register them.
Depending on numbers, we may be able to open the registration to siblings of children with T1D at a closer date.
Would you like to register more children if spaces are available? Select 'yes' and we'll be in touch if possible.
Yes
No
Page 4
Will you be attending the Sundowner Session at 4.45pm? This is for adults only and costs $15 per person; your ticket includes canapes and drinks (select beer, wine, soft drinks and juices).
Yes
No
How many additional adults will be attending?
Please select...
0
1
2
3
4
5
Payment details
Cardholder Name
Credit card number
Expiry month
Expiry year
CVC code
Cardholder email
Amount
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