American Diabetes Association: Survey - Sign up form for Advocacy Attorney Network

Sign up form for Advocacy Attorney Network

Learn more about the Advocacy Attorney Network at http://www.diabetes.org/attorneyswanted

Please send questions to attorneynetwork@diabetes.org

Contact Information


*	First Name: Required
*	Last Name: Required
*	E-mail: Required
*	Street 1: Required
*	City: Required
*	State / Province: Required
*	Zip / Postal Code: Required
	Phone Number:
	Remember me. What's this?

Question - Not Required - Firm Name

Question - Not Required - Preferred contact method

Question - Not Required - In what jurisdictions are you licensed to practice law?

Question - Not Required - Please note what geographic areas you will take cases

Question - Not Required - Please describe your legal practice (type of law practiced, size of firm, etc.)

Question - Not Required - Will you provide a free consultation to individuals referred by the American Diabetes Association?

Question - Not Required - Comments:

Question - Not Required - If representation results from the consultation, it will be:

Question - Not Required - Comments:

Please indicate whether you are interested in working on the following diabetes discrimination issues:

Question - Not Required - Employment

Question - Not Required - Education/Safe at School Campaign

Question - Not Required - Daycare/Childcare programs

Question - Not Required - Jails/Prisons

Question - Not Required - Police misconduct

Question - Not Required - Public accommodations

Question - Not Required - Driver's Licenses

Question - Not Required - Other issues (please indicate):

Question - Not Required - Would you be willing to assist the ADA on legislative initiatives?

Question - Not Required - Comments:

Question - Not Required - Are you interested in joining the ADA Advocacy Attorney Network listserv? If so, please indicate what e-mail address we should use for this list:

Question - Not Required - Do you have any personal connection to diabetes?

Question - Not Required - Any additional comments:

By completing this form, you are signing up to join the ADA Advocacy Attorney Network

Question - Not Required - I am ready to help now

Question - Not Required - I have questions and would like to speak to a staff member before being contacted for referrals

Learn more about the Advocacy Attorney Network at http://www.diabetes.org/attorneyswanted

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