Start a Chapter of the College Diabetes Network

About You!










Diabetes Connection-Select "yes" for the statement that best describes you.




Your Health Info









Your Chapter/School Information







Name of individual who referred you to this form.




Please include a couple different dates and times that work best. Don't forget to include your timezone!
Mailing Address
When we receive your form, we'll mail you a copy of our Chapter Handbook! The Chapter Handbook is full of helpful tips and guidance in getting your Chapter started. 

Please give us the best mailing address for us to send you a copy of our Chapter Handbook: