Kids Walk - Register Your School

School Coordinator Name and Email Address:

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Name:

First Required	Last Required

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Email: Required

Yes, I would like to receive e-mail from JDRF

Remember me. What's this?

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Question - Required - School Name

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Question - Required - School Address

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Question - Required - City

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Question - Required - State

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Question - Required - Zip

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Question - Required - Phone

Position:

(Select one of the available choices or enter a different value.)
Question - Not Required -

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Question - Required - We would like to hold our Kids Walk during the month of

Question - Not Required - Goal (the average school raises $3000):

Question - Not Required - How did you hear about the Kids Walk to Cure Diabetes program?

	Parent
	JDRF staff member or volunteer
	Conference
	Mailing
	Website
	Other

Question - Not Required - If you selected Other above, please specify:

Question - Not Required - Number of students attending your school

Question - Not Required - Grade levels (check all that apply)

Question - Not Required - Chapter: