Membership Form "*" indicates required fields Step 1 of 5 20% Personal InformationIn this section we will ask for your contact information for the membership application.Name* First Name Last Name Email Address* Enter the email address you would like on your membership record.Phone Number*Enter the phone number you would like used on your membership record.Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Enter the address you would like to use on your membership record. At times we may mail you items of interest. Optional Personal InformationDate of Birth Month Day Year Enter your date of birth.Gender I identify as a female I identify as a male Other Prefer not to answer Ethnicity Asian Black or African American Hispanic or Latino Middle Eastern or North African Multiracial or Multiethnic Native American or Alaska Native Native Hawaiian or other Pacific Islander South Asian White – Anglo-Caucasian I prefer not to answer Other Occupation or Last Occupation Worked Hobbies and Interests Medical InformationWhat is your diabetes type? Not diabetic Pre diabetic Gestational Type 1 Type 2 Other What is your current vision status? Sighted Partially Sighted Blind Newsletter PreferencesACBDA Newsletter* Do not Receive the ACBDA Newsletter Receive the ACBDA newsletter via email ACB Braille and E-Forum Newsletter* I would like to receive the Forum newsletter via email I would like to receive the Forum newsletter in large print I would like to receive the Forum newsletter in braille I would like to receive the Forum newsletter on a National Library Service (NLS) Cartridge I do not wish to receive the Forum newsletter Committees of InterestPlease check off any of the following committees that you might be interested in serving on as a part of the affiliate.Committees of Interest Fundraising: plan and coordinate activities to raise sustaining funds for affiliate Budget/Finance: prepares annual budget, oversees investments, reviews annual books/audit Peer Mentor Relations: oversees and manages peer-to-peer support program, inclusive of matching mentors with mentees Membership: promotes membership growth and member retainment Education: organizes and coordinates speaker pipeline for Living Better with Diabetes, tracks and maintains topics and speakers Constitution and Bylaws: oversees and manages any amendments to the constitution and bylaws Convention: plans and coordinates convention program, contact speakers Legislation and Advocacy: tracks congressional legislation, educates board and ACBDA members about advocacy, assists in crafting resolutions Nominating: seeks current (dues paid) members to serve on the board, prepares slate of candidates for election Website: oversees and manages ACBDA’s website Patricia LaFrance Wolf Memorial Fund: oversees and manages member emergency fund, reviews applications, determines eligibility and amount given Sunshine: Distributes Encouragement and get well cards Select AllPlease check off any of the following committees that you might be interested in serving on as a part of the affiliate. Membership DuesPlease select one of the following four options below to determine the amount owed to the affiliate.ACBDA Membership ACBDA full membership (without discounts) - ($10) ACBDA Full Life Time Membership (without discounts) - ($250) ACBDA Membership (with discounts as a life member of ACB or ACBDA) - ($5) ACBDA Membership (with discounts as a life member of both ACB and ACBDA) - ($0) Check OutTotal Membership Dues owed Payment MethodPayPal CheckoutCredit Card American ExpressDiscoverMasterCardVisaMaestroSupported Credit Cards: American Express, Discover, MasterCard, Visa, Maestro Card Number Expiration Date Security Code Cardholder Name Please use PayPal to pay your membership dues. Δ