Application form

Thank you very much for your interest in the pre-qualifications of the Junior Cup Diabetes 2012. Before you start the application process, please take a minute to review the criteria for participation with your parent/caregiver.

The criteria for participation to the pre-qualifications of the Junior Cup diabetes 2012 are as follows:

Your child has type 1 diabetes
Your child is between 8-12 years old at the time of the pre-qualifications
My child has never participated in the Junior Cup Diabetes before

* Required fields
Mandatory field Your name*
Mandatory field Your child's name*
Mandatory field Your child's sex:*
Mandatory field Birthdate of your child*
Mandatory field Your e-mail address*
Mandatory field Your telephone number*
Mandatory field Address*
Mandatory field Zip code*
Mandatory field City*
Mandatory field Country:*
Mandatory field Does your child receive Insulin Pump Therapy treatment?*
If yes, for how many years now?:
If yes, please select the manufacturer
Mandatory field Does your child receive Multi Daily Injections treatment?*
Mandatory field What size clothing does your child wear?*
Mandatory field What shoe size does your child have?*
Mandatory field Is your child a member of a football club?*
If yes, which football club and which team?
Which position does your child play on the field?
Data protection You accept that: Your personal data (name, address, telephone number, e-mail address, information relating to health) will be collected, processed and stored by Medtronic in accordance with all applicable data protection laws. Medtronic will use and share this information only with its affiliates and third party service providers, who carry out services on its behalf, solely for the purpose of the organization of the Junior Cup 2012. You may be contacted by Medtronic concerning event satisfaction. Please click here to confirm that you accept all terms and conditions:
	I accept the terms and conditions
Any subsequent changes, such as to contact details will have to be communicated via your local Junior Cup contact person.

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Application form