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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!

 

1.
Question - Not Required - YES! Send an Everyday Wisdom Kit for families of kids recently diagnosed with diabetes. (Please limit to one kit per household)

2.
Question - Not Required - YES! Match us with a parent mentor who will help my family!

3.
Question - Not Required - YES! Send information about the American Diabetes Association's research, education, advocacy and local programs.

4.
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.

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

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Name:

 

 

   

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City/State/ZIP:

 

    

 

 

 


*6.


7.  


8.
Question - Not Required - Child's Gender:


9.
Question - Not Required - Child's Birthdate:




10.
Question - Not Required - Child's Date of Diagnosis:




11.


12.
Question - Not Required - How did you hear about this program? (Please pick one.)
Please make up to 1 selection from the choices below.

13.  


  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.

   Please leave this field empty

 

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