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

(for reaching you as a network member)

First Name: 

Last Name: 

Address: 

Address 2: 

City: 

State:  

Zip Code: 

Your Professional Website (or LinkedIn): 

Place of Business: 

Email Address: 

Home Phone (optional): 

Work Phone: 

Mobile Phone: 

 

Professional Background, Experience & Skills

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











 

2. Please state your specialty

 

3. In which setting(s) do you work? Select all that apply.






 

4. Please indicate your expertise and knowledge about diabetes.

 

5. Are you a Certified Diabetes Educator (CDE)?

 

6. If you provide health care services in languages other than English, please list them

 

7. Please select all states in which you are willing to volunteer as an HCP Network Member.

 

Health Care Professional Legal Advocacy Network Member Preferences

8. In which of the following areas are you interested in providing service, as an HCP Network Member? Select all that apply.

 

9. In which of the following functions are you interested in providing service, as a Network Member? Select all that apply.

 

Engagement With The American Diabetes Association

10. How did you learn about the Health Care Professional (HCP) Legal Advocacy Network?

 

11. What was the primary motivation for you to become a member of the HCP Legal Advocacy Network?

 

12. How have you have been involved with the American Diabetes Association? Select all that apply.


 

13. The HCP Legal Advocacy Network Listserv, carefully moderated by experts, provides a valuable forum for discussion about discrimination due to diabetes. If you prefer that we use an email other than the address you provided above, list it here

 :

14. Check the box below — 

 

15. 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