Signup for our Newsletter Join the network! (DEMO) Thanks for your interest in signing up to receive our newsletter and joining the CDN network! When you sign up, you’ll not only receive the latest CDN and CDN partner news, but you’ll have access to awesome deals and discounts on diabetes products, accessories, apps and events to make life with T1D a little sweeter. I am best described as aYoung Adult (e.g. 16-30)Family Member / Caregiver of Someone with DiabetesClinician / Health Care ProviderCampus Administration / FacultyOrganization RepresentativeOther Contact and Demographic Info First Name Last Name Email Address If you are a student, please provide a personal email that you will check year-round! City StatePlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia Other Postal Code Birthdate (mm/dd/yyyy) Race / EthnicityPlease select... Asian or Pacific Islander Black or African American Hispanic or Latino Middle Eastern or North African Native American or American Indian White Other I prefer not to say I am a person living with...Type 1 diabetesType 2 diabetesAnother form of diabetesI don't have diabetesPrefer not to answer Diagnosis Date (mm/dd/yyyy) I am the parent of a child living with type 1 diabetes.TrueFalse Education Information I am currently best described as the following.Not in high school or college right nowCurrent High School StudentCurrent Undergraduate StudentUndergraduate AlumCurrent Graduate / Professional StudentGraduate Alum Expected High School Graduation Date (mm/dd/yyyy) Are you planning to go to college/university?YesNo Do you know what college/university you will be attending?YesNo College/University Name (Undergrad): Expected Undergraduate Graduation Date (mm/dd/yyyy) College/University Name (Graduate): Expected Graduate Program Graduation Date (mm/dd/yyyy) Clinical Provider Information Name of Institution/Clinic where employed: Title: I hold the following credential(s). Endocrinologist Certified Diabetes Educator Registered Nurse Psychologist Social Worker Primary Care Provider Physician's Assistant Nurse Practitioner I am specialized in diabetes / related conditions.TrueFalse My practice is primarily focused in the following population.Adult CarePediatricsBoth Campus Faculty or Administration I am employed in the following capacity on campus Professor / Faculty Campus Administration What school / university do you work at? Title I am employed by the following campus office(s). Accessibility / Disability Services Admissions Dining Services Mental Health Counseling Services Residence Life Student Affairs Student Health Services I hold the following credential(s). Endocrinologist Certified Diabetes Educator Registered Nurse Psychologist Social Worker Primary Care Provider Physician's Assistant Nurse Practitioner Caregiver Information Would you like to give us more information about your child with diabetes? Yes No Your child's information Child's First Name Child's Last Name Child's Email Address: Child's Birthdate (mm/dd/yyyy) My child has...Type 1 diabetesType 2 diabetesAnother form of diabetesPrefer not to answer Which best describes your child?Not in high school or college right nowCurrent High School StudentCurrent College StudentUndergraduate Alum Expected High School Graduation Date (mm/dd/yyyy) Do you know what college/university your child will be attending? YesNo What college/university? Expected Undergrad Graduation Date (mm/dd/yyyy) To add another child, please select "Add another response" below. Membership Would you like to be a part of the CDN Network and receive news, updates and special offers from our partners?YesNo Are you interested in participating in research opportunities through CDN?YesNo Privacy Policy Contact Information
