Living with Diabetes

Learn more about the Advocacy Attorney Network at: http://www.diabetes.org/attorneyswanted

Contact Information

First Name:

Last Name:

Address:

Address 2:

City:

State:

Please select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Health List TEST Health List Test Landing page Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Your Professional Website (or LinkedIn):

Place of Business:

Email Address:

Home Phone (optional):

Work Phone:

Mobile Phone:

Professional Background, Experience & Skills

1. In which states(s) are you licensed to practice law?

Please select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Health List TEST Health List Test Landing page Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

2. In which states in which you are willing to volunteer as a Network Member?

Please select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Health List TEST Health List Test Landing page Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

3. What is your practice setting?

Sole practitionerPrivate firm—office of 2-25 lawyersPrivate firm—office of 26-50 lawyersPrivate firm—office of 51+ lawyersGovernment agencyNonprofit organizationOther

4. What types of law do you practice? Check all that apply.

AdministrativeCivil RightsCorporateCriminal DefenseDisability RightsDiscriminationEducationEmployee BenefitsEmploymentGeneral PracticeHealth CareLaborPersonal InjuryPrisoners' RightsUnemploymentOther

Other (please specify):

5. What specific discrimination law experience do you have? Please note: experience in discrimination law is appreciated, but not necessary. Check all that apply.

EmploymentEducationDaycare/ChildcareCorrectional FacilitiesPolice MisconductPublic AccomodationsDrivers' LicensesOther: Specify belowNone of the above- I do not have any discrimination law experience

5a. Other: List your other specific discrimination law experience:

6. Do you provide legal services in languages other than English?

YesNo

If yes, please list additional language(s) in which you provide legal services:

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

EmploymentEducationDaycare/ChildcareCorrectional FacilitiesPolice MisconductPublic AccomodationsDrivers' LicensesOther

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

Providing legal consultationsMaking phone calls (e.g. calling employers, schools, etc)Writing letters (e.g. requesting school/work accommodations, etc.)Litigating casesConsulting on casesAssisting with legislative effortsEducating individuals about their rights (e.g. presentations, lectures)Presenting information about the Advocacy Attorney Network to othersHelping to recruit new members of the Advocacy Attorney Network

9. Are you able to provide a free consultation to individuals referred to you by the Association?

YesNo

10. In general, after initial consultation, what fee structure(s) are you able to consider? Select all that apply.

Pro bonoContingencyFlat feeHourly rateRetainerAll of the aboveOther (specify below)

Other fee structure options:

11. How did you learn about the Advocacy Attorney Network?

Professional ColleaguePresentation at conference/meeting/other eventAmerican Diabetes AssociationADA Advocacy Attorney Network Business CardFamily/FriendOther (specify below):

Other (please specify):

12. What was the primary motivation for you to become a member of the Advocacy Attorney Network?

I have a strong personal connection to diabetes (e.g., self, child, other family member, friend with diabetes)I wanted to volunteer/advocate for an important causeI wanted to leverage my professional skills/experience in a meaningful wayOther (specifiy below)

Other (please specify):

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

Joined the Stop Diabetes movementSubscribed to Diabetes Forecast magazineSubscribed to a professional member publicationSubscribed to e-newslettersDonated moneyVolunteered (in a Non-Advocacy Attorney Network capacity)Attended a Diabetes EXPOPurchased books, materials, or videos from the American Diabetes Association’s online storeParticipated in Step Out: Walk to Stop Diabetes eventParticipated in a Tour de Cure eventChild attended a Diabetes CampParticipated in an online message board Participated (or child participated) in School Walk for Diabetes eventOther (specify below):

13a. Other: List other ways you have been involved with the American Diabetes Association:

14. The Advocacy Attorney Network Listserv provides a valuable forum for robust discussion about discrimination due to diabetes. If you prefer that we add a different email address than the one you provided above, please list it here:

 I do NOT want to be a member of this listserv

15. When you join the Advocacy Attorney Network, you also become a Diabetes Advocate; you will regularly receive urgent Action Alerts and information about how you can help Stop Diabetes through advocacy.

 I do NOT want to become a Diabetes Advocate (to regularly receive urgent Action Alerts and information about how you can help Stop Diabetes through advocacy)

16. If you want to recommend a colleague for us to contact for recruitment into the Advocacy Attorney or Health Care Professional Legal Advocacy 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 Advocacy Attorney Network.