American Diabetes Association: Tell Us More!

Special Notice

The Everyday Wisdom Kit is intended only for parents and caretakers of children with type 1 diabetes. While the kits are free, there is a limited supply. Please only order the kit for your child with type 1 diabetes. Thank you.

Tell Us More!

Question - Not Required - YES! Send an Everyday Wisdom Kit for families of kids recently diagnosed with diabetes. (Please limit to one kit per household)

Yes

Question - Not Required - YES! Match us with a parent mentor who will help my family!

Yes

Question - Not Required - YES! Send information about the American Diabetes Association's research, education, advocacy and local programs.

Yes

Question - Not Required - YES! I want to subscribe to Diabetes Forecast magazine for $28. Send me a free trial issue. If I like it, send me 11 more issues. Otherwise, I will mark the invoice "Cancel", return it and enjoy my one free issue.

Yes

Please enter parent's name and address information (NOTE: At this time we are unable to accept PO Boxes or addresses outside the US.):

Name:

First Required	Last Required

E-mail: Required

Street 1: Required

Street 2:

City/State/ZIP:

City Required	State Required	ZIP Required

Phone Number:

Gender:

Yes, I would like to receive periodic updates and communications from the American Diabetes Association.

*6.

Question - Required - The address above is my

Question - Not Required - Child's Name:

Question - Not Required - Child's Gender: Male
Female

Question - Not Required - Child's Birthdate:

Month

Day

Year

10.

Question - Not Required - Child's Date of Diagnosis:

Month

Day

Year

11.

Question - Not Required - Child's Ethnicity:

12.

Question - Not Required - How did you hear about this program? (Please pick one.)
Please make up to 1 selection from the choices below.

	Everyday Wisdom Kit
	Hospital
	Diabetes Expo
	School Nurse
	Pediatric Endocrinologist
	Local American Diabetes Association Office
	Diabetes Educator
	1-800-DIABETES
	Dietitian

13.

Question - Not Required - If none of the above, please enter how you heard about this program:

The American Diabetes Association welcomes your feedback, questions or suggestions any time. Please e-mail youth@diabetes.org or call 1-800-DIABETES (1-800-342-2383).

Thank you.

American Diabetes Association 1701 North Beauregard Street Alexandria, VA 22311 1-800-DIABETES (800-342-2383)

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