Personal Information
First Name
Last Name
Email
Phone
Preferred Pronouns
What is your connection to diabetes?
Please select...
I have type-1 diabetes
I have type-2 diabetes
I have another form of diabetes
Personal connection (family/friend with diabetes)
Professional connection/interest
Approached by student leader
Other
Other Connection to Diabetes (please describe)
Current Position
College / University Name
Please enter the full name of your college / university - no abbreviations please!
Title / Role
Department
Do you have any contacts in the following departments? We’d love to connect with them!
Disability or Accessibility Services
Health Services
Counseling Services
Other
Other Contacts
Additional Contact First Name
Additional Contact Last Name
Additional Contact Email
Additional Contact Title / Role
Additional Contact Department
Chapter Engagement
Is there currently a Diabetes Link chapter at your school?
Yes
No
I don't know
How involved are you in your school's chapter?
Very involved
Somewhat involved
Not involved at all
Please Explain.
Are you willing to serve as this Chapter's faculty advisor if no one is currently in that role?
Yes
No
I am currently their advisor
Regarding your school’s diabetes community, please tell us what you’re most passionate about.
Not passionate
Somewhat passionate
Very passionate
Spreading diabetes awareness and education
Advocacy efforts (supporting students in creating ‘low blood sugar stations’ on campus, developing a standard set of accommodations through disability services, etc.)
Administrative or background support (budgeting, registering as a club, reserving rooms, etc.)
Reaching the broader community (high schools, children’s hospitals, etc.)
Other (Please describe)
Other (Please describe)
May we contact you directly about future opportunities to participate in The Diabetes Link’s broader Campus Advocate work?
Yes
No
Would you like to sign up for our quarterly Campus Advocate Newsletter?
Yes
No
Contact Information