About You!

I am a ...

First Name

Last Name

Birthday

Phone

Email Address

Please provide an email that you will check often!

Title / Position:

Gender

Ethnicity

Anticipated Undergraduate Graduation Date

College Major

Anticipated Graduate Graduation Date

I am a person living with...

What is your connection to diabetes?

Connection to diabetes (other)

Your Health Info

Diagnosis Date

Diagnosed as a young adult

YesNo

Current Diabetes Clinic

Pumper?

YesNo

Pump Model

Type of Insulin

CGM user?

YesNo

CGM Model

Your Chapter/School Information

College/University

College/University City

College/University State

College/University Postal Code

If you already lead any other campus groups or organizations, tell us about it here!

How do you want to get involved with The Diabetes Link?

Why do you want to start a chapter and what are your aspirations for your campus?

Are you aware of others on campus interested in starting or getting involved in a chapter?

While faculty and campus administration cannot start a chapter directly, they can help to set the foundation on campus and assist in finding students to lead the group. Are you aware of any student(s) on campus interested in starting or getting involved with a chapter?

What kind of support do you feel like you can offer to a chapter or students on your campus?

What departments on campus do you currently have connections / relationships with?

When are you interested in starting your chapter? Once we receive your form, a staff member from The Diabetes Link will be in touch to schedule a call with you to go over next steps.

Please include a couple different dates and times that work best. Don't forget to include your timezone!

How did you hear about us?

How did you hear about us- other

Yes, I'd like to receive emails from The Diabetes Link!

YesNo

Mailing Address

Please share your current mailing address.

Mailing Street

Mailing City

Mailing State/Province

Mailing ZIP/Postal Code

Are you interested in starting a chapter?

YesNo