Juvenile Diabetes Research Foundation

Juvenile Diabetes Research Foundation

Greater Iowa Chapter Outreach Interest Survey

Date: ______

Name: ______

Home Address: ______

City: ______State: _____ Zip: ______

Email: ______Home telephone: ______Cell Phone: ______

Employer: ______Work telephone: ______

Spouse / Significant Other: ______

Employer: ______Work telephone: ______

How did you hear of the Juvenile Diabetes Research Foundation (JDRF)? ______

Do you have a family connection to Diabetes? Yes No

**(If you or a member of your family has diabetes, continue. If no connection, please skip to Company

questions on page 2)

Does an adult in your family have diabetes? Yes NoType 1? Type 2?

Please list adult family members with diabetes: ______

Hospital/Endocrinologist affiliation: ______

Do you have a child with diabetes? Male Female

Date of birth: ______Date of Diagnosis: ______Age at diagnosis: _____Hospital/Endocrinologist: ______Telephone: ______

Did you receive the Bag of Hope/Teen Pack? Yes No Was it helpful? Yes No

School: ______Grade: ______

Extracurricular Activities: ______

Please list siblings and ages: ______

Family Networking Groups

Please mark a group that interests you or a family member:

Networking/Support for Adults with Type 1.

Topics of interest: ______

Networking/Support for Parents of a young child with diabetes.

Topics of interest: ______

Networking/Support for Families with children activities going on simultaneously.

Topics or activities of interest: ______

Networking/Support for Teens.

Topics of interest: ______

Additional groups that would be of interest: ______

Meeting frequency: Monthly Bi-Monthly Quarterly

Preferred days and times: ______

Does your community have an active support group? Yes No

Please describe the group: ______

May we add this group to our resource manual and website? Yes No

If yes, please list contact and meeting information: ______

______

Please list any other ways that JDRF can assist your family: ______

Would you be willing to assist in coordinating a support group in your area? Yes No

Would you be willing to host a parent coffee or arrange a venue? Yes No

Babysitting Resources

Would a list of babysitting resources be helpful to you? Yes No

Please list any babysitters, teen or adult, who are willing to baby sit for a child with diabetes:

______

Mentoring Program

Would you be interested in speaking with another parent of a child with diabetes who lives in your community or has a child of the same age as yours? Yes No

Volunteer Opportunities

Please check all that interest you:

Hand delivery of Bags of Hope/Teen Packs (provided to newly diagnosed children and teens).

Being a mentor, providing support for parents of newly diagnosed children via phone and/or email.

Assisting in coordination of support groups.

Assisting in family event planning.

Assisting in programming at schools to include: educational programs; development of 504 plans.

Being an advocate through the government relations committee; public speaking; media relations.

Assist with the Walk to Cure Diabetes (planning committee, fundraising, volunteer, team, etc.).

Assist with various local fundraisers as needed.

Please list other ways that you may be able to assist JDRF and families living with type 1: ______

CompanySupport

Would your place of employment be interested in providing in-kind or monetary donations for the Gala?

Yes Please explain: ______No

Does your company have a matching gift program? ? Yes No

Would your company be interest in sponsorship opportunities for the Walk to Cure Diabetes or Gala?

Yes Please explain: ______No

Does your company support community volunteering?

Yes Please explain: ______No

Would your company be interested in a third-party fundraising event for JDRF?

Yes Please explain: ______No