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ELBOWBUMPKID INC

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NEWLY DIAGNOSED T1D FAMILIES

If you are newly diagnosed with Type 1 Diabetes in Connecticut, Rhode Island or Western Massachusetts, we understand the challenges and medical expenses that come with this diagnosis. We are committed to supporting you and your family during this journey. Please complete the form, and someone will contact you via email soon.

Name of parent - First name *

Name of parent - Last name*

First name of child*

Age of child*

Gender of child

Street Address*

City*

State*

Zip Code*

Endo Provider

CCMC

Yale

Other

Date of Diagnosis*

Do you use a Dexcom CGM yet? If yes, which version?

Do you use an insulin pump yet yet? If so, which pump? If not, are you planning on staying on multiple daily injections long-term?*

Do you have celiac disease as well as Type 1 Diabetes?*

Siblings ages

What shirt size is the T1D?

Is your family economically disadvantaged, receiving government assistance or income at poverty levels? If you answer no, you have completed this form after you click SUBMIT and someone will outreach you soon. If yes, the form continues.*

Yes

How many family members live in your household?

Are you receiving government assistance?

Yes

Are one or both parents unemployed or income at poverty levels? What non-medical items have you purchased for your T1D since diagnosis? What items do you wish you had funds to purchase?

We have the following items available as supplies last for economically disadvantaged families - please check box next to each item that you haven't purchased yet:

Supply belt

Insulin cooler for hot weather sports / travel

Food scale

Pip pain free lancets

Insulin vial protector

Sling bag

Dexcom G7 adhesives

Dexcom monitoring tool (Teenagers or college students only)

Discounts provided by the following:

Spibelt

Pain Care Labs

4imprint

4all Family

Frio

PumpPeelz

Sugar Medical

Glowcose

Custom Type 1

Pip Diabetes Care

Information provided by the following:

Finding Smiles Coaching

Touched by Type 1

Lauren's Hope

Camp Surefire

Breakthrough T1D

Diamyd

Connor Parkinson

Mail:

P.O. Box 603, Higganum, CT 06441

CONTACT US

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