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• 2013 Arizona Diabetes Day

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2013 Arizona Diabetes Day

1.	Your Information (please provide your home address, not work address): * Name: First Required  Last Required      * E-mail: Required * Street 1: Required * City/State/ZIP: City Required State Required  ZIP Required    AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AS FM GU MH MP PR PW VI AA AE AP AB BC MB NB NL NS NT NU ON PE QC SK YT None     Phone Number:   Gender: Male Female   Yes, I would like to receive e-mail from American Diabetes Association   Remember me. What's this?
2.	Question - Not Required - Do you have a connection with diabetes? Please make between 1 and 5 selections from the choices below. Yes, I have type 1 Yes, I have type 2 Yes, I have pre-diabetes Yes, I have a child or children with diabetes I have a family member with diabetes No, I am just concerned about the issue
*3.	Question - Required - Are you a health care professional? Please select response No Physician Nurse Diabetes Educator Researcher Dietitian/Nutritionist Student Pharmacist Other health care professional
4.	Question - Not Required - If you answered "other health care professional," what type of health care professional are you?
*5.	Question - Required - Have you scheduled a meeting with your legislators? Please select response Yes, I have scheduled a meeting already. No, but I intend to soon. No, I have not scheduled a meeting and need help doing so. No, I cannot meet on 3/28/13, but will try to meet at another time.
6.	Question - Not Required - If yes to the above question, tell us who the appointment is with and the time and room of the appointment.
7.	Question - Not Required - Are you on a first-name basis with any Arizona legislators? If yes, please tell us who and what your connection is.
*8.	Question - Required - What is your t-shirt size? S M L XL XXL
*9.	Question - Required - Do you require any special accommodations? Please select response Yes No
10.	Question - Not Required - If you answered "Yes" above, please describe the accommodation(s) needed.
11.	Question - Not Required - If you are bringing another family member, please put their name here: (Maximum response 255 chars, approx. 5 rows of text)

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American Diabetes Association 1701 North Beauregard Street Alexandria, VA 22311 1-800-DIABETES