Application Form

All applications, including the biography and video must be submitted online by Friday, August 3rd, 2018 by MIDNIGHT EDT.

*Name of Child:

*Age:

*Date of Birth:

*Name of parent/guardian:

*Address:

*City:

*Province:

*Postal Code:

*Home Phone:

Work Phone:

Child's E-mail:

*Parent's E-mail:

*Local JDRF Chapter:

*Your Member of Parliament:

To find your Member of Parliament, go to the parl.gc.ca website and enter your postal code.

*Please indicate which language you are fluent in :

English

French

Other

If other please indicate which one:

Please list your social media channels below (if applicable):
Twitter: Handle:      
Followers:  
Facebook:  Yes          No
Instagram: Handle:      
Followers:  

CHILD APPLICANT

Tell us about yourself.
Write a one-page biography about yourself. We want to hear your personal story and how you live with T1D every day. We also want to know why a cure for T1D is important to you, and the ways in which you are involved with JDRF. Tell us about any previous involvement you’ve had with JDRF and why you believe research to be important.
 

*Please upload a recent photo of your child (head and shoulders preferred)


*Please include your name in the biography and upload it below (.doc, .pdf, .txt)

 

Do you have a parent, sibling or other relative(s) with type 1 diabetes? If yes, indicate relation:

What are your interests, hobbies and activities?

Do you have any accomplishments you are proud of?

What do you want to do when you grow up?

Have you participated in a clinical trial before?

If so, please tell us what trial, the year of the trial, and share your experience.

If applicable, what have you done to promote awareness of type 1 diabetes (T1D) in your local community?

Is there anything else you would like the JDRF Advocacy Volunteer Selection Committee to know about you and/or your family?


PARENT/GUARDIAN CONSENT

By submitting the online application I, as a parent or guardian, I agree to abide by the rules, conventions, and terms of JDRF’s Kids for a Cure Lobby Day:

  • Allow JDRF to use my child’s name and story in print, radio, television, internet (with appropriate safeguards), and in any other appropriate media to promote JDRF’s mission and goals.
  • While other family members are welcome to accompany the delegate at their own expense, only the parent/guardian identified in the application will be able to accompany the delegate to the meetings and reception on Parliament Hill.
  • Applicants must be committed to further developing a relationship with their Member of Parliament (MP) after lobby day is over.

I also indicate my understanding that:

  • There may be discussion of the complications of diabetes during JDRF’s Kids for a Cure Lobby Day.


*PHOTO/VIDEO CONSENT

 I consent to the use of my child’s photo/video in print and online (including social media) for the purposes of promoting JDRF and this event. If you have questions or concerns related to photo/video consent or otherwise throughout this process, please contact Patrick Tohill, Director of Government Relations.
 

EMAIL CONSENT

 I consent to receive electronic messages from JDRF Canada, including emails, text messages, social network messages, contest notifications, publications, e-newsletters, updates, announcements, events, promotions and invitations. This information will not be shared and you will always have the option to unsubscribe.

 

Comments/Questions:

   

Lets turn type one into type none