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Bag of Hope Request

Bag of Hope Request

The Bag of Hope is a complimentary over-the-shoulder satchel filled with a variety of educational and reference materials. For children under the age of 12, the Bag of Hope also includes Rufus, the Bear with Diabetes ™, a plush bear designed to help children learn about insulin injections.

Please complete the form below to receive a Bag of Hope for a child, or yourself.

Please complete the form below to receive a Bag of Hope for a child.

*First Name of Parent:

*Last Name of Parent:

Street Address (unable to ship to postal box):

*City:

*Province:

*Postal Code:

*Phone Number:

E-mail:


 

 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.
 

Diabetes Relationship:

 Myself

 My Child

 Immediate Family Member

Name of Child with T1D:

Date of Birth (mm/dd/yyyy):

Gender:

 Male

 Female

Diagnosis Date (mm/dd/yyyy):

Clinic Name:

 

 
 

* Required Fields

You can view our Privacy Policy to see how we use the information we collect.

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