Back to Basics Registration Form

In Melbourne, Sydney and Adelaide, Reality Check invites you to join us as we get our heads around all that is the big D, ask all the questions we’ve been sitting on for years and fill in all the gaps.

It’ll be seriously informative but still very relaxed and cruisy…

To Register for Back to Basics, please complete the form below.

I would like to come to:	Back to Basics Melbourne - Sat 4th September Click here for full Melbourne program and details Registrations close Friday 20th August
Name
Email Address
Street
Suburb
State
Postcode
Mobile Phone Number We will send you an SMS reminder!
Other Daytime Phone Number
I am:	Type 1 Type 2 Partner Health Professional Other
Gender	Male Female
Date of Birth
Age Diagnosed
I would like to bring a partner/friend with me too (just $5 each).
Partner/Friend's Name/s:
Partner/Friend's Email:
Partner/Friend's Mobile Number:
How did you find out about Back to Basics?	Email from Reality Check Flyer that came in the Mail My Doctor/Nurse Told Me Friend Told Me Other (please explain below)
Any questions or comments? When you are done >>>

You will receive an email response to confirm your registration for Back to Basics.

$10 per person is payable on the day. (Cash only please!)
If you bring a friend or partner, they pay just $5 each.
Price inclues showbag, afternoon snacks, speakers' notes and a real drink at the end!

If you have further queries about Back to Basics at any time, please contact Rebecca on rebecca@realitycheck.org.au or phone 03 9328 5233.

Privacy Note: Reality Check young adults with diabetes Inc. is committed to protecting your privacy. Email addresses or mailing addresses are never, under any circumstance, provided to another organisation, group, company or individual who is not an authorised representative of our organisation, for any purpose other than that by which you provided your details to us originally.