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I am best described as a
Young Adult (e.g. 16-30)
Family Member / Caregiver of Someone with Diabetes
Clinician / Health Care Provider
Campus Administration / Faculty
Organization Representative
Other
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
Please 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 / Ethnicity
Please 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 diabetes
Type 2 diabetes
Another form of diabetes
I don't have diabetes
Prefer not to answer
Diagnosis Date (mm/dd/yyyy)
I am the parent of a young adult living with diabetes.
True
False
Education Information
I am currently best described as the following.
Not in high school or college right now
Current High School Student
Current Undergraduate Student
Undergraduate Alum
Current Graduate / Professional Student
Graduate Alum
Expected High School Graduation Date (mm/dd/yyyy)
Are you planning to go to college/university?
Yes
No
Do you know what college/university you will be attending?
Yes
No
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.
True
False
My practice is primarily focused in the following population.
Adult Care
Pediatrics
Both
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 diabetes
Type 2 diabetes
Another form of diabetes
Prefer not to answer
Which best describes your child?
Not in high school or college right now
Current High School Student
Current College Student
Undergraduate Alum
Expected High School Graduation Date (mm/dd/yyyy)
Do you know what college/university your child will be attending?
Yes
No
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 Diabetes Link network and receive news and updates from our partners?
Yes
No
Are you interested in participating in research opportunities through The Diabetes Link?
Yes
No
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Contact Information