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Name*

First Last

Email*

Enter Email Confirm Email

Address

State / Province / Region Country

Please let us know about where you live.

Date of Birth*

We ask for your birth date so that we can limit what is used on the website if you are under 18.

Date Diagnosed

If you don't know the exact day, don't worry. Just choose the correct month and/or correct year and note this in your story.

Your Story*

Please tell us about yourself and your connection to diabetes.

Your Photo

Accepted file types: jpg, jpeg, png, Max. file size: 25 MB.

If you have a photo, upload it here.

Short Bio

Please include a short bio of yourself so we can consider it for inclusion with the story. This will appear underneath your photo.

Consent to Use My Story and Photo*

I agree with terms below.

By submitting my information, photo, and/or video, I give Children with Diabetes permission to use my story, imagery, photograph(s), and/or video(s), in its promotional materials and publicity efforts. I understand that the imagery may be used in, but not limited to, a publication, print ad, direct-mail piece, electronic media, or other form or promotion; and that my name and additional information collected by the organization may be used in conjunction with the image(s). I release Children with Diabetes from liability for any violation of any personal or proprietary right I may have in connection with such use.

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