childrenwithdiabetes.com
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2606:4700:20::ac43:46e2
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Submitted URL: http://www.childrenwithdiabetes.com//pumps
Effective URL: https://childrenwithdiabetes.com/pumps
Submission: On July 01 via api from US — Scanned from DE
Effective URL: https://childrenwithdiabetes.com/pumps
Submission: On July 01 via api from US — Scanned from DE
Form analysis 6 forms found in the DOM
GET https://childrenwithdiabetes.com/
<form role="search" method="get" class="search-form" action="https://childrenwithdiabetes.com/">
<label for="search-field">
<span class="screen-reader-text">Search for:</span>
<input type="search" id="search-field" class="search-field" placeholder="Search..." value="" name="s" tabindex="-1">
</label>
<input type="submit" class="search-submit" value="Search">
</form>GET https://childrenwithdiabetes.com
<form role="search" method="get" id="searchform" class="searchform" action="https://childrenwithdiabetes.com">
<div>
<label class="screen-reader-text" for="swpquery">Search for:</label>
<input type="text" placeholder="Search" value="" name="s" id="s">
<input type="hidden" name="engine" value="default">
<input type="submit" id="searchsubmit" value="Search">
</div>
</form>POST /pumps#gf_21
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_21" id="gform_21" action="/pumps#gf_21" data-formid="21" novalidate="" class="recaptcha-v3-initialized">
<div class="gf_invisible ginput_recaptchav3" data-sitekey="6LcSfpAcAAAAAAtE4JX0nbUBNWFrPYHi1cfB8Ha2" data-tabindex="0"><input id="input_a8b1513e03b5683f22703299db37f394" class="gfield_recaptcha_response" type="hidden"
name="input_a8b1513e03b5683f22703299db37f394" value=""></div>
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="gform-body gform_body">
<ul id="gform_fields_21" class="gform_fields top_label form_sublabel_below description_below validation_below">
<li id="field_21_1" class="gfield gfield--type-name gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_1"><label
class="gfield_label gform-field-label gfield_label_before_complex">Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row" id="input_21_1">
<span id="input_21_1_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_1.3" id="input_21_1_3" value="" aria-required="true">
<label for="input_21_1_3" class="gform-field-label gform-field-label--type-sub ">First</label>
</span>
<span id="input_21_1_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_1.6" id="input_21_1_6" value="" aria-required="true">
<label for="input_21_1_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
</span>
</div>
</li>
<li id="field_21_2" class="gfield gfield--type-email gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_2"><label
class="gfield_label gform-field-label gfield_label_before_complex">Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container ginput_container_email gform-grid-row" id="input_21_2_container">
<span id="input_21_2_1_container" class="ginput_left gform-grid-col gform-grid-col--size-auto">
<input class="" type="email" name="input_2" id="input_21_2" value="" aria-required="true" aria-invalid="false">
<label for="input_21_2" class="gform-field-label gform-field-label--type-sub ">Enter Email</label>
</span>
<span id="input_21_2_2_container" class="ginput_right gform-grid-col gform-grid-col--size-auto">
<input class="" type="email" name="input_2_2" id="input_21_2_2" value="" aria-required="true" aria-invalid="false">
<label for="input_21_2_2" class="gform-field-label gform-field-label--type-sub ">Confirm Email</label>
</span>
<div class="gf_clear gf_clear_complex"></div>
</div>
</li>
<li id="field_21_11" class="gfield gfield--type-address gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_11"><label
class="gfield_label gform-field-label gfield_label_before_complex">Address</label>
<div class="ginput_complex ginput_container has_state has_country ginput_container_address gform-grid-row" id="input_21_11">
<span class="ginput_right address_state ginput_address_state gform-grid-col" id="input_21_11_4_container">
<input type="text" name="input_11.4" id="input_21_11_4" value="" aria-required="false">
<label for="input_21_11_4" id="input_21_11_4_label" class="gform-field-label gform-field-label--type-sub ">State / Province / Region</label>
</span><span class="ginput_right address_country ginput_address_country gform-grid-col" id="input_21_11_6_container">
<select name="input_11.6" id="input_21_11_6" aria-required="false">
<option value=""></option>
<option value="Afghanistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bonaire, Sint Eustatius and Saba">Bonaire, Sint Eustatius and Saba</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cabo Verde">Cabo Verde</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos Islands">Cocos Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curaçao">Curaçao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czechia">Czechia</option>
<option value="Côte d'Ivoire">Côte d'Ivoire</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Eswatini">Eswatini</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands">Falkland Islands</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories">French Southern Territories</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See">Holy See</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option>
<option value="Korea, Republic of">Korea, Republic of</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia">Micronesia</option>
<option value="Moldova">Moldova</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="North Macedonia">North Macedonia</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestine, State of">Palestine, State of</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Romania">Romania</option>
<option value="Russian Federation">Russian Federation</option>
<option value="Rwanda">Rwanda</option>
<option value="Réunion">Réunion</option>
<option value="Saint Barthélemy">Saint Barthélemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin">Saint Martin</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten">Sint Maarten</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Georgia and the South Sandwich Islands">South Georgia and the South Sandwich Islands</option>
<option value="South Sudan">South Sudan</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria Arab Republic">Syria Arab Republic</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania, the United Republic of">Tanzania, the United Republic of</option>
<option value="Thailand">Thailand</option>
<option value="Timor-Leste">Timor-Leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Türkiye">Türkiye</option>
<option value="US Minor Outlying Islands">US Minor Outlying Islands</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United States" selected="selected">United States</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Venezuela">Venezuela</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands, British">Virgin Islands, British</option>
<option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
<option value="Åland Islands">Åland Islands</option>
</select>
<label for="input_21_11_6" id="input_21_11_6_label" class="gform-field-label gform-field-label--type-sub ">Country</label>
</span>
<div class="gf_clear gf_clear_complex"></div>
</div>
<div class="gfield_description" id="gfield_description_21_11">Please let us know about where you live.</div>
</li>
<li id="field_21_4"
class="gfield gfield--type-date gfield--input-type-datedropdown gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_21_4"><label class="gfield_label gform-field-label">Date of Birth<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div id="input_21_4" class="ginput_container ginput_complex gform-grid-row">
<div class="clear-multi">
<div class="gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col" id="input_21_4_1_container"><select name="input_4[]" id="input_21_4_1" aria-required="true">
<option value="">Month</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select></div>
<div class="gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col" id="input_21_4_2_container"><select name="input_4[]" id="input_21_4_2" aria-required="true">
<option value="">Day</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select></div>
<div class="gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col" id="input_21_4_3_container"><select name="input_4[]" id="input_21_4_3" aria-required="true">
<option value="">Year</option>
<option value="2025">2025</option>
<option value="2024">2024</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
<option value="1923">1923</option>
<option value="1922">1922</option>
<option value="1921">1921</option>
<option value="1920">1920</option>
</select></div>
</div>
</div>
<div class="gfield_description" id="gfield_description_21_4">We ask for your birth date so that we can limit what is used on the website if you are under 18.</div>
</li>
<li id="field_21_3" class="gfield gfield--type-date gfield--input-type-datedropdown gf_left_half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_3">
<label class="gfield_label gform-field-label">Date Diagnosed</label>
<div id="input_21_3" class="ginput_container ginput_complex gform-grid-row">
<div class="clear-multi">
<div class="gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col" id="input_21_3_1_container"><select name="input_3[]" id="input_21_3_1" aria-required="false">
<option value="">Month</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select></div>
<div class="gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col" id="input_21_3_2_container"><select name="input_3[]" id="input_21_3_2" aria-required="false">
<option value="">Day</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select></div>
<div class="gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col" id="input_21_3_3_container"><select name="input_3[]" id="input_21_3_3" aria-required="false">
<option value="">Year</option>
<option value="2025">2025</option>
<option value="2024">2024</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
<option value="1923">1923</option>
<option value="1922">1922</option>
<option value="1921">1921</option>
<option value="1920">1920</option>
</select></div>
</div>
</div>
<div class="gfield_description" id="gfield_description_21_3">If you don't know the exact day, don't worry. Just choose the correct month and/or correct year and note this in your story. </div>
</li>
<li id="field_21_6" class="gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_6"><label
class="gfield_label gform-field-label" for="input_21_6">Your Story<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_6" id="input_21_6" class="textarea medium" aria-describedby="gfield_description_21_6" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea>
</div>
<div class="gfield_description" id="gfield_description_21_6">Please tell us about yourself and your connection to diabetes.</div>
</li>
<li id="field_21_5" class="gfield gfield--type-fileupload field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_5"><label
class="gfield_label gform-field-label" for="input_21_5">Your Photo</label>
<div class="ginput_container ginput_container_fileupload"><input type="hidden" name="MAX_FILE_SIZE" value="26214400"><input name="input_5" id="input_21_5" type="file" class="medium"
aria-describedby="gfield_upload_rules_21_5 gfield_description_21_5" onchange="javascript:gformValidateFileSize( this, 26214400 );"><span class="gfield_description gform_fileupload_rules" id="gfield_upload_rules_21_5">Accepted file types:
jpg, jpeg, png, Max. file size: 25 MB.</span>
<div class="gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty" id="live_validation_message_21_5"></div>
</div>
<div class="gfield_description" id="gfield_description_21_5">If you have a photo, upload it here.</div>
</li>
<li id="field_21_9" class="gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_9"><label
class="gfield_label gform-field-label" for="input_21_9">Short Bio</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_9" id="input_21_9" class="textarea medium" aria-describedby="gfield_description_21_9" aria-invalid="false" rows="10" cols="50"></textarea></div>
<div class="gfield_description" id="gfield_description_21_9">Please include a short bio of yourself so we can consider it for inclusion with the story. This will appear underneath your photo.</div>
</li>
<li id="field_21_8"
class="gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_21_8"><label class="gfield_label gform-field-label gfield_label_before_complex">Consent to Use My Story and Photo<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_consent"><input name="input_8.1" id="input_21_8_1" type="checkbox" value="1" aria-describedby="gfield_consent_description_21_8" aria-required="true" aria-invalid="false"> <label
class="gform-field-label gform-field-label--type-inline gfield_consent_label" for="input_21_8_1">I agree with terms below.</label><input type="hidden" name="input_8.2" value="I agree with terms below." class="gform_hidden"><input
type="hidden" name="input_8.3" value="11" class="gform_hidden"></div>
<div class="gfield_description gfield_consent_description" id="gfield_consent_description_21_8">By submitting my information, photo, and/or video, I give Children with Diabetes permission to use my story, imagery, photograph(s), and/or
video(s), in its promotional materials and publicity efforts. I understand that the imagery may be used in, but not limited to, a publication, print ad, direct-mail piece, electronic media, or other form or promotion; and that my name and
additional information collected by the organization may be used in conjunction with the image(s). I release Children with Diabetes from liability for any violation of any personal or proprietary right I may have in connection with such
use. </div>
</li>
<li id="field_21_10" class="gfield gfield--type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_21_10">
<div class="ginput_container ginput_container_text"><input name="input_10" id="input_21_10" type="hidden" class="gform_hidden" aria-invalid="false" value="2a01:4a0:1338:93::4"></div>
</li>
</ul>
</div>
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<input type="hidden" name="pum_form_popup_id" value="56349">
</form>POST /pumps#gf_2
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_2" id="gform_2" class="newquestionform recaptcha-v3-initialized" action="/pumps#gf_2" data-formid="2" novalidate="">
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<div class="gform-body gform_body">
<ul id="gform_fields_2" class="gform_fields top_label form_sublabel_below description_below validation_below">
<li id="field_2_18" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_2_18">
<h3 style="text-align:center;">Help Us Understand You Better.</h3>
<p>Please answer a few questions to help us understand how best to serve you. <strong>You are not required to answer, but we hope you will.</strong> This information will be collated and may be published on our website periodically, or may be
used for publication, but we will use composite data only. We do not maintain any individual data from these items. If you ask another question at a later time, please fill this out each time. </p>
<p> This form is just for questions related to diabetes care. If you have questions about anything else related to Children with Diabetes, please use our <a href="https://childrenwithdiabetes.com/contact/">Contact Us</a> form. </p>
</li>
<li id="field_2_1" class="gfield gfield--type-select gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_2_1"><label
class="gfield_label gform-field-label" for="input_2_1">This question is on behalf of:</label>
<div class="ginput_container ginput_container_select"><select name="input_1" id="input_2_1" class="large gfield_select" aria-invalid="false">
<option value="Please select">Please select</option>
<option value="Myself">Myself</option>
<option value="My child">My child</option>
<option value="My grandchild">My grandchild</option>
<option value="My spouse or partner">My spouse or partner</option>
<option value="My parent">My parent</option>
<option value="Another relative">Another relative</option>
<option value="A friend">A friend</option>
<option value="My girlfriend or boyfriend">My girlfriend or boyfriend</option>
<option value="My patient">My patient</option>
<option value="Other">Other</option>
</select></div>
</li>
<li id="field_2_2" class="gfield gfield--type-select gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_2_2"><label
class="gfield_label gform-field-label" for="input_2_2">The question applies to this age group:</label>
<div class="ginput_container ginput_container_select"><select name="input_2" id="input_2_2" class="large gfield_select" aria-invalid="false">
<option value="Please select">Please select</option>
<option value="Under two years old">Under two years old</option>
<option value="Between 2 and 5 years old">Between 2 and 5 years old</option>
<option value="Between 6 and 12 years old">Between 6 and 12 years old</option>
<option value="Between 13 and 18 years old">Between 13 and 18 years old</option>
<option value="Between 19 and 40 years old">Between 19 and 40 years old</option>
<option value="Between 41 and 60 years old">Between 41 and 60 years old</option>
<option value="Over 60 years old">Over 60 years old</option>
</select></div>
</li>
<li id="field_2_3" class="gfield gfield--type-select gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_2_3"><label
class="gfield_label gform-field-label" for="input_2_3">This question relates to:</label>
<div class="ginput_container ginput_container_select"><select name="input_3" id="input_2_3" class="large gfield_select" aria-invalid="false">
<option value="Please select">Please select</option>
<option value="Type 1 diabetes">Type 1 diabetes</option>
<option value="Type 2 diabetes">Type 2 diabetes</option>
<option value="Gestational diabetes">Gestational diabetes</option>
<option value="Other diabetes : Other diagnosed diabetes">Other diabetes : Other diagnosed diabetes</option>
<option value="Diabetes, suspected">Diabetes, suspected</option>
<option value="Hypoglycemia, diagnosed">Hypoglycemia, diagnosed</option>
<option value="Hypoglycemia, suspected">Hypoglycemia, suspected</option>
<option value="PCOS">PCOS</option>
<option value="Don't know">Don't know</option>
<option value="Other illness">Other illness</option>
</select></div>
</li>
<li id="field_2_4" class="gfield gfield--type-select gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_2_4"><label
class="gfield_label gform-field-label" for="input_2_4">We've had diabetes for:</label>
<div class="ginput_container ginput_container_select"><select name="input_4" id="input_2_4" class="large gfield_select" aria-invalid="false">
<option value="Please select">Please select</option>
<option value="Less than six months">Less than six months</option>
<option value="Less than one year">Less than one year</option>
<option value="Less than two years">Less than two years</option>
<option value="Less than five years">Less than five years</option>
<option value="Less than 10 years">Less than 10 years</option>
<option value="10 years or more">10 years or more</option>
<option value="Doesn't apply">Doesn't apply</option>
<option value="Don't know">Don't know</option>
</select></div>
</li>
<li id="field_2_5" class="gfield gfield--type-select gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_2_5"><label
class="gfield_label gform-field-label" for="input_2_5">We use this treatment for diabetes:</label>
<div class="ginput_container ginput_container_select"><select name="input_5" id="input_2_5" class="large gfield_select" aria-invalid="false">
<option value="Please select">Please select</option>
<option value="Takes insulin injections">Takes insulin injections</option>
<option value="Uses an insulin pump">Uses an insulin pump</option>
<option value="Takes oral diabetes medications">Takes oral diabetes medications</option>
<option value="Takes insulin and oral medications">Takes insulin and oral medications</option>
<option value="Uses diet and exercise only">Uses diet and exercise only</option>
<option value="Diabetes, without medications : Has diabetes but doesn't take any medications">Diabetes, without medications : Has diabetes but doesn't take any medications</option>
<option value="Diabetes, no treatment plan : Has diabetes but doesn't have a treatment plan">Diabetes, no treatment plan : Has diabetes but doesn't have a treatment plan</option>
<option value="Doesn't apply">Doesn't apply</option>
<option value="Other">Other</option>
</select></div>
</li>
<li id="field_2_6" class="gfield gfield--type-select gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_2_6"><label
class="gfield_label gform-field-label" for="input_2_6">We have the following insurance:</label>
<div class="ginput_container ginput_container_select"><select name="input_6" id="input_2_6" class="large gfield_select" aria-invalid="false">
<option value="Please select">Please select</option>
<option value="Private insurance through an employer">Private insurance through an employer</option>
<option value="Private insurance that I/my parents pay for">Private insurance that I/my parents pay for</option>
<option value="Medicare/Medicaid/other US/state funded plan">Medicare/Medicaid/other US/state funded plan</option>
<option value="National health care outside the US">National health care outside the US</option>
<option value="Self-insured">Self-insured</option>
<option value="Uninsured">Uninsured</option>
<option value="Don't Know">Don't Know</option>
<option value="Other">Other</option>
</select></div>
</li>
<li id="field_2_7" class="gfield gfield--type-select gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_2_7"><label
class="gfield_label gform-field-label" for="input_2_7">We receive diabetes care from:</label>
<div class="ginput_container ginput_container_select"><select name="input_7" id="input_2_7" class="large gfield_select" aria-invalid="false">
<option value="Please select">Please select</option>
<option value="A general practice or family practice doctor : A general practice or family practice doctor">A general practice or family practice doctor : A general practice or family practice doctor</option>
<option value="A general pediatrician">A general pediatrician</option>
<option value="A general internal medicine physician">A general internal medicine physician</option>
<option value="Another doctor plus an endocrinologist or diabetes specialist">Another doctor plus an endocrinologist or diabetes specialist</option>
<option value="An endocrinologist or diabetes specialist only">An endocrinologist or diabetes specialist only</option>
<option value="A nurse practitioner or physician assistant working for a general physician">A nurse practitioner or physician assistant working for a general physician</option>
<option value="A nurse practitioner or physician assistant working for an endocrinologist or diabetes specialist : A nurse practitioner or physician assistant working for an endo or diabetes specialist">A nurse practitioner or physician
assistant working for an endocrinologist or diabetes specialist : A nurse practitioner or physician assistant working for an endo or diabetes specialist</option>
<option value="Another health professional">Another health professional</option>
<option value="No health professional at the present time">No health professional at the present time</option>
<option value="Don't know">Don't know</option>
<option value="Other">Other</option>
</select></div>
</li>
<li id="field_2_8" class="gfield gfield--type-select gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_2_8"><label
class="gfield_label gform-field-label" for="input_2_8">I'm asking this question because:</label>
<div class="ginput_container ginput_container_select"><select name="input_8" id="input_2_8" class="large gfield_select" aria-invalid="false">
<option value="Please select">Please select</option>
<option value="I need a second opinion">I need a second opinion</option>
<option value="The doctor or diabetes team didn't give me the answer I wanted">The doctor or diabetes team didn't give me the answer I wanted</option>
<option value="I'm not comfortable asking this of the doctor">I'm not comfortable asking this of the doctor</option>
<option value="I want to know this before I talk to the doctor">I want to know this before I talk to the doctor</option>
<option value="I don't have a doctor">I don't have a doctor</option>
<option value="Other">Other</option>
</select></div>
</li>
<li id="field_2_19" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_2_19"><br><br>
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