Tell Us More!

Question - Not Required - YES! Send an Everyday Wisdom kit for families of kids recently diagnosed with diabetes.

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! Send us the free Family Link E-newsletter, Homefront Magazine and trial issue of Diabetes Forecast.

Yes

Please enter parent's name and address information:

Name:

First Required	Last Required

E-mail: Required

Street 1:

Street 2:

City/State/ZIP:

City	State	ZIP

Phone Number:

Yes, I would like to receive e-mail from American Diabetes Association

Remember me. What's this?

Question - Not Required - Child's Name:

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

Question - Not Required - Child's Birthdate:

Month

Day

Year

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

Month

Day

Year

10.

Question - Not Required - How did you hear about this program? Please pick one.
Please make up to 1 selections 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

11.

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).

12.

Question - Not Required - Ethnicity: