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I am best described as a

Young 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

State

Postal Code

Birthdate (mm/dd/yyyy)

Race / Ethnicity

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

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 The Diabetes Link network and receive news, updates and special offers from our partners?

YesNo

Are you interested in participating in research opportunities through The Diabetes Link?

YesNo

Contact Information