American Diabetes Association: Survey - LWT2D Sign Up (English)

1.

Just fill in this short form and you can receive your first information packet in seconds!


	Title:
*	First Name: Required
*	Last Name: Required
	Suffix:
*	E-mail: Required
	Street 1:
	Street 2:
	City:
	State / Province:
*	Zip / Postal Code: Required
*	Country: Required
	Phone Number:
	Date of Birth:	Date of Birth:
	Yes, I would like to receive e-mail from American Diabetes Association
	Keep me logged in. What's this? Remembers your login information for your convenience. Use only on trusted, private computers. Privacy Policy

2.

Question - Not Required - What is your race/ethnicity?

3.

Question - Not Required - Approximate Date of Diagnosis

Month

Day

Year

4.

Question - Not Required - How did you hear about the program?

5.

Question - Not Required - We send our information by email, if you prefer to receive the information by postal mail, check the following box. Your first package will arrive within 4 to 6 weeks.

Yes, I want to receive the information packets through the postal service.

6.

Question - Not Required - Above address is:

7.

Question - Not Required - Above phone number is

8.

Question - Not Required - We distribute our information packets via email. If you prefer to receive information through the postal service, instead, check the box below. Your first packet will arrive in the mail in 4-6 weeks.

9.

Question - Not Required - What is the highest level of education that you have completed?

10.

Question - Not Required - What is your gender?

11.

Question - Not Required - As a resident of countries affected by GDPR, we are required to request your consent and acknowledgement that you authorize us to store your data by checking this box.

12.

Question - Not Required - Cell Phone:

13.

Question - Not Required - Work Phone:

14.

Question - Not Required - How old were you when you were diagnosed with diabetes?

15.

Question - Not Required - By checking this box you agreed that we may reach out to you on your mobile phone. Charges may apply for text messages etc.

16.

Question - Not Required - LWT2D Sign Up Date

Month

Day

Year

17.

Question - Not Required - What is your personal relationship to an individual with diabetes?

18.

Question - Not Required - Partner_Source