American Diabetes Association: Survey

1.

Your info

*

Name:

First Required	Last Required

*

E-mail: Required

City/State/ZIP:

City	State	ZIP

Country:

Phone Number:

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

*2.

Question - Required - Your Story

*3.

Question - Required - I give consent

4.

Question - Not Required - Tell us what Social Media Platform you are using (i.e facebook, twitter, instagram, etc)

5.

Question - Not Required - What is the name of your social media handle used in the above platform?

(Maximum response 255 chars, approx. 5 rows of text)

6.

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.

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