Membership Form "*" indicates required fields Step 1 of 6 16% Personal InformationIn this section we will ask for your contact information for the membership form.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 / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 WorkedHobbies and InterestsMedical 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 Program: 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 Web site: oversees and manages ACBDA’s web site Patricia LaFrance Wolf Memorial Fund: oversees and manages member emergency fund, reviews applications, determines eligibility and amount given Select AllPlease check off any of the following committees that you might be interested in serving on as a part of the affiliate. Sharing Personal InformationSharing Information with Leadership and committee Members Can we share your membership information with the committee chairs? It is often helpful to share information with our committee chairs and other leadders. We need your help in verifying if you will allow us to share your membership data with these leaders. Membership DuesPlease select one of the following four options below to determine the amount owed to the affiliate.ACBDA Membership ACBDA full membership for 1 year (without discounts) - ($10) ACBDA full membership for 4 years and get the fifth year free - ($40) ACBDA Full Life Time Membership (without discounts) - ($250) ACBDA Membership for 1 year (with discounts as a life member of ACB or ACBDA) - ($5) ACBDA Membership for 1 year (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