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2017-2018 Diabetes Awareness Essay Contest District 2-X1 Application Form
“Accepting a Diabetes Diagnosis: What can Parents, Partners, and Caretakers do to help love ones adjust to a new normal”.
Name ______________________________ DOB ___________________ M / F Address ____________________________________________________________ ____________________________________________________________
E-Mail _______________________________ Phone _______________________ Parent/Guardian Name _______________________________________________ Parent E-Mail _________________________ Phone ________________________ School Currently Attending __________________ City _________ 11th/12th grade College Plan to Attend ____________________ Expected Enrollment Year______ Sponsoring Lions Club ____________________ Club Contact _________________ Contact E-Mail __________________________ Phone______________________ _____________________ _____________________ ______________________ Signatures: Contestant Parent/Guardian Club President
Return this form , a typed copy of the essay and $100 (payable to 2X1 Charities) provided by the sponsoring Lions Club to :
Lion Gloria Mathur, 8705 Baltusrol Dr. , Flower Mound , TX 75022, gmathur1@tx.rr.com 972-896-9953
NOTE: These forms can be downloaded from our District 2-X1 website under the resources drop down tab. Look for “District Forms” and under Youth Contest Award select your form to download.
VOLUME 28 ISSUE 5 / NOVEMBER 2017 PAGE 15