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Your Name(Required)

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Preferred Method of Contact

Your Email Address(Required)

Email Address Confirm Email Address

Cell Phone Number

Address

Street Address City State / Province / Region ZIP / Postal Code

Do you have a child (18 or younger) with diabetes?(Required)

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In order to best serve your child with diabetes and family, please share your child's name and date of birth. This information helps us to provide you with the best information and programs that would be appropriate for your child.

Name of Child with Diabetes

Birthdate of Child with Diabetes

What is your interest in Camp Seale Harris (check all that apply)?(Required)

I would like to get Camp Seale Harris's e-news delivered to me.

I want information about Camp Seale Harris programs for my child/family member (camps, support, activities).

I want to donate to Camp Seale Harris.

I used to attend Camp Seale Harris.

Your Comments/Questions

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