Email:

Street:

Phone

Cell Phone

Work Phone

Your Professional Website (or Linkedin):

Place of Business:

In which state(s) you are licensed to practice law?
Select all that apply by hold down the CTRL key when making multiple selections.

Select one or more state AL AK AR AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC NC OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI none

In which states in which you are willing to volunteer as a Network Member?
Select all that apply by hold down the CTRL key when making multiple selections.

Select one or more state AL AK AR AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC NC OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI none

What is your practice setting?

Select an answer Sole Practitioner Private firm - office of 2 - 25 lawyer Private firm - office of 26-50 lawyer Private firm - office of 50+ lawyer Government Agency Nonprofit Organization

What types of law do you practice?
Select all that apply by hold down the CTRL key when making multiple selections.

Select all that applies Administrative Civil Rights Corporate Criminal Defense Disability Rights Discrimination Education Employee Benefits Employment General Practice Health Care Labor Personal Injury Prisoners Rights Unemployment Other

If you select "Other" on the above, please specify:

What specific discrimination law experience do you have?
Select all that apply by hold down the CTRL key when making multiple selections.

Select all that applies Employment Education Daycare/Childcare Correctional Facilities Police Misconduct Public Accomodations Drivers Licenses Other None

If you select "Other" on the above, please specify:

Yes, I do provide legal services in languages other than English

If yes, please list additional language(s) in which you provide legal services:

In which of the following areas are you interested in providing service, as a Network Member?
Select all that apply by hold down the CTRL key when making multiple selections.

Select all that applies Employment Education Daycare/Childcare Correctional Facilities Police Misconduct Public Accomodations Drivers Licenses

In which of the following functions are you interested in providing service, as a Network Member?
Select all that apply by hold down the CTRL key when making multiple selections.

Select all that applies Providing legal consultations Making phone calls Writing letter Litigating cases Consulting on cases Assisting with legislative efforts Educating individuals about their rights Presenting information about Advocacy Attorney Network to others Helping to recruit new members of the Advocacy Attorney Network

Yes, I am able to provide a free consultation to individuals referred to you by the Association

In general, after initial consultation, what fee structure(s) are you able to consider?
Select all that apply by hold down the CTRL key when making multiple selections.

Select all that applies Pro bono Contingency Flat fee Hourly rate Retainer All of the above Other

If you select "Other" on the above, please specify:

How did you learn about the Advocacy Attorney Network?

Select an answer Professional Colleague Presentation at conference/meeting/other event American Diabetes Association ADA Advocacy Attorney Network Business Card Family/Friend Other

If you select "Other" on the above, please specify:

What was the primary motivation for you to become a member of the Advocacy Attorney Network?

Select an answer I have a strong personal connection to diabetes I wanted to volunteer/advocate for an important cause I wanted to leverage my professional skills/experience in a meaningful way Other

If you select "Other" on the above, please specify:

How have you have been involved with the American Diabetes Association?
Select all that apply by hold down the CTRL key when making multiple selections.

Select all that applies Joined the Stop Diabetes movement Subscribed to Diabetes Forecast magazine Subscribed to a professional member publication Subscribed to e-newsletters Volunteered Attended a Diabetes EXPO Made purchases from ADA online store Participated in Step Out Participated in a Tour de Cure Child attended a Diabetes Camp Participated in an online message board Participated in School Walk for Diabetes event Other

If you select "Other" on the above, please specify:

Do you want to become a Diabetes Advocate?

Do you want to be included into American Diabetes Association listserv for this?

If you want to recommend a colleague for us to contact for recruitment into the Advocacy Attorney or Health Care Professional Legal Advocacy Network, please list their name(s), email address(es), and professional title(s).

  I am ready to help
  I have questions and would like to speak with a staff member before I sign up as a Network Member.

To identify that you are a real human, please solve below problem: