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Date of Birth:

 

If you respond and have not already registered, you will receive periodic updates and communications from American Diabetes Association.

 

What's this?

 
Question - Not Required - The address above is my:


 
Question - Not Required - Do you have diabetes?






 
Question - Not Required - Does your spouse have diabetes?






 
Question - Not Required - Are you the parent of a child with diabetes?






 
Question - Not Required - What type of diabetes exists in your family? (choose most prevalent type)






 
Question - Not Required - What is your ethnicity?








 
Question - Not Required - Yes, I'd like to become a Diabetes Advocate!


 


 
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