SAMPLE REQUEST FORM
FOR CHILDRENS DIABETES CAMPS

We at Dex4 believe that hypoglycemia preparation, education and awareness are very important. Camp directors should educate the parents of campers to prepare their children before going to camp with the necessary supplies needed to successfully manage their children’s diabetes. As we all know, children are very active at camp and it is critical that parents and children understand how to treat hypoglycemia. Helpful educational support is available in the Learning Center for parents and children to learn more about hypoglycemia, how to treat this condition, and how Dex4 fast-acting glucose works faster than candy, cola and juice. Dex4 is happy to support diabetes camps with fast-acting glucose products. If you are affiliated with a diabetes camp and would like to receive free Dex4 glucose products, please complete the form below:

Requestor Details Name:  
Camp Name:  
Phone:   E-Mail:   Fax:  
Camp Information Camp Director:  

Camp Season:
Number of campers expected:   Or
Camp dates and session length:   Or

Camp Season:
Number of campers expected: Or
Camp dates and session length: Or

Camp Season:
Number of campers expected: Or
Camp dates and session length: Or
Shipping Address: (Please allow 3 to 4 weeks for delivery) Delivery Date:  
Attn:  
Camp Name:  
Address:  
City:   State:   Zip:  
Phone  
E-Mail:  
Fax:  
Samples (Enter desired amount) **Please note that depending on inventory availability, requested quantities may be reduced.**

Glucose Pouch Packs
Glucose 50ct Bottles
Glucose 10ct Tablets
Glucose 2oz Gel Tubes
Glucose 2oz Liquid Bottles

On behalf of the Dex4 team, we thank you for educating and raising awareness of hypoglycemia and emphasizing the importance of always being prepared with Dex4 fast-acting glucose products. For more information to encourage patents and children about hypoglycemia, Dex4 glucose products and where to buy, please visit Dex4.com. Please note we will do our best to honor all requests; however, do to the fluctuation of sample inventories we may find it necessary to adjust/limit the samples you receive.