About You!
I am a ...
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Undergraduate student
Graduate student
Faculty on a college campus
Administrator on a college campus
Other
First Name
Last Name
Birthday
Phone
Email Address
Please provide an email that you will check often!
Title / Position:
Gender
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Male
Female
Other
Ethnicity
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White
Black or African American
Hispanic or Latino
Native American or American Indian
Asian or Pacific Islander
Other
I prefer not to say
Anticipated Undergraduate Graduation Date
College Major
Anticipated Graduate Graduation Date
I am a person living with...
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type 1 diabetes
type 2 diabetes
another form of diabetes
I do not have diabetes
What is your connection to diabetes?
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I have type-1 diabetes
I have type-2 diabetes
I have another form of diabetes
I am a parent or caregiver of someone with diabetes
Other (please describe)
Connection to diabetes (other)
Your Health Info
Diagnosis Date
Diagnosed as a young adult
Yes
No
Current Diabetes Clinic
Pumper?
Yes
No
Pump Model
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Tandem
Minimed/Medtronic
Insulet/OmniPod
iLET
Other
Type of Insulin
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Apidra
Humalog
Novolog
Lantus
Afrezza
Levemir
Toujeo
FIASP
CGM user?
Yes
No
CGM Model
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Dexcom
Medtronic
Abbot FreeStyle Libre
Eversense
Your Chapter/School Information
College/University
College/University City
College/University State
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Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
North Carolina
North Dakota
Northern Mariana Islands
Nova Scotia
Ohio
Oklahoma
Ontario
Oregon
Palau
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Island
Virginia
Washington
West Virginia
Wisconsin
Wyoming
College/University Postal Code
How do you want to get involved with The Diabetes Link?
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Start a chapter on my campus
Join a chapter
Learn more about The Diabetes Link
Why do you want to start a chapter and what are your aspirations for your campus?
If you already lead any other campus groups or organizations, tell us about it here!
Are you aware of others on campus interested in starting or getting involved in a chapter?
While faculty and campus administration cannot start a chapter directly, they can help to set the foundation on campus and assist in finding students to lead the group. Are you aware of any student(s) on campus interested in starting or getting involved with a chapter?
What kind of support do you feel like you can offer to a chapter or students on your campus?
What departments on campus do you currently have connections / relationships with?
When are you interested in starting your chapter? Once we receive your form, a staff member from The Diabetes Link will be in touch to schedule a call with you to go over next steps.
Please include a couple different dates and times that work best. Don't forget to include your timezone!
x
How did you hear about us?
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Instagram
TikTok
Facebook
LinkedIn
Google Search
Off to College Event
The Diabetes Link website
The Diabetes Link email/ newsletter
Through my diabetes camp
Word of Mouth
Printed materials
A Campus Chapter/ Student Member
From another nonprofit organization
From my parent/caregiver
From my child
From my Endo/CDE/clinician
Other
How did you hear about us- other
Referral Name (Optional):
Name of individual who referred you to this form.
Yes, I'd like to receive emails from The Diabetes Link!
Yes
No
Mailing Address
Please share your current mailing address.
Mailing Street
Mailing City
Mailing State/Province
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Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
North Carolina
North Dakota
Northern Mariana Islands
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Palau
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
Mailing ZIP/Postal Code
Are you interested in starting a chapter?
Yes
No
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