School Consultation
MI Life in Numbers Student / Parent Consent Form

**MI Life in Numbers is committed to providing support to all people living with type one diabetes and their support networks in our service area regardless of their race, ethnicity, religious or cultural affiliation, age, gender identity, sexual orientation, age, economic status, or other identifying factors.**

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Student Information
Full Name *
Birth Date *
MM
/
DD
/
YYYY
Gender
Email (if applicable)
Phone Number (if applicable)
Student's Street Address (include city, state, zip code) *
School Name & School District *
Diabetes Diagnosis Date *
MM
/
DD
/
YYYY
Please list any diabetes supplies used (Medtronic pump, Dexcom CGM, shots, etc.) *
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