Join the Health Care Professionals Legal Advocacy Network


Registration Form

Learn more about the Health Care Professionals Legal Advocacy Network at http://www.diabetes.org/patientrights

Contact Information

First Name: 

Last Name: 

Facility: 

Department:  

Address: 

Address 2: 

City: 

State:  

Zip Code: 

Email Address: 

Your Professional Website (or LinkedIn): 

Work Phone: 

Mobile Phone: 

 

Professional Background, Skills and Interest

1. Which of the following credentials do you currently hold? Select all that apply.











 

2. Please state your specialty, if applicable:

 

3. Please select all states in which you are willing to help:

 

Health Care Professional Legal Advocacy Network Member Preferences

4. In which areas are you interested in helping? Select all that apply.

 

5. How would you like to help? Select all that apply.

Engagement with The American Diabetes Association

6. How have you have been involved with the American Diabetes Association? Select all that apply, if applicable.


7. Check the box below — 

 

8. If you want to recommend a colleague for us to contact for recruitment into the HCP Network or the Advocacy Attorney Network, please list their name(s), email address(es), and professional title(s).

By completing this form, you are signing up to participate in the ADA Health Care Professionals Legal Advocacy Network. There is no fee to participate and no annual requirement for volunteering.