Facility:

Department:

Email:

Street:

Phone

Cell Phone

Work Phone

Your Professional Website (or Linkedin):

Which of the following credentials do you currently hold?
Select all that apply by hold down the CTRL key when making multiple selections.

Select all that applies CDE - Certified Diabetes Educator DO - Doctor of Osteopathy MD - Doctor of Medicine BSW,LSW, MSW - Social Worker RN - Registered Nurse NP - Nurse Practitioner PA - Physician's Assistant PhD - Doctorate PharmD/RPH - Registered Pharmacist/Doctor of Pharmacy RD - Registered Dietitian Other

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

Please state your specialty, if applicable:

Please state(s) in which you are willing to help:
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 areas are you interested in helping?
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 Driver Licenses Other

How would you like to help?
Select all that apply by hold down the CTRL key when making multiple selections.

Select all that applies Assisting with the development of diabetes-related educational materials Educating individuals about their rights Making phone calls Writing letters Training Consulting with attorneys on legal cases Being an expert witness at trials Supporting the Association's legislative efforts New Member Recruitment

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 Donated money Volunteered Attended a Diabetes EXPO Made purchases on the ADA online store Participated in Step Out Participated in Tour de Cure Child attended a Diabetes Camp Participated in an online community Participated in School Walk Attended the Scientific Sessions Conference Other

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

Do you want to become a Diabetes Advocate?

If you want to recommend a colleague for us to contact for recruitment into the HCP Network or the Advocacy Attorney 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 to a staff member before I help

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