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POCLWD Summit

First name/ Nombre

Last name/ Apellido

Email/ Correo electrónico

Ethnicity

Hispanic or Latino / Hispano o Latino

Not Hispanic or Latino / No Hispano o Latino

Race

American Indian or Alaska Native / Indio americano o nativo de Alaska

Asian / Asiático

Black or African American / Negro o afroamericano

Native Hawaiian or Other Pacific Islander / Nativo de Hawái u otra isla del Pacífico

White / Blanco

Two or more races / Dos o más razas

Prefer not to answer / Prefiere no responder

Relation to Diabetes

Person living with Diabetes/ Persona que vive con diabetes

Family Member or Friend of Someone with Diabetes/ Familiar o amigo(a) de alguien con diabetes

Healthcare Professional / Educator/ Profesional de la salud / Educador(a)

Advocate / Community Leader/ Defensor(a) / Líder comunitario(a)

Researcher or Student/ Investigador(a) o estudiante

What do you hope to get from the summit. (Community, education, resources...) / ¿Qué espera obtener del evento? (Comunidad, educación, recursos...)

How did you hear about this event? / ¿Cómo se enteró de este evento?

Social media / Redes sociales

Email / Correo electrónico

Friend or family / Amigo o familiar

Healthcare provider / Profesional de salud

Flyer or poster / Volante o cartel

Other / Otro

Do you have any accessibility needs or accommodations?/ ¿Tiene alguna necesidad de accesibilidad o adaptación?

Do you want to get connected more with Diversity in Diabetes / ¿Quiere involucrarse más con Diversity in Diabetes?

Do you consent to Diversity in Diabetes to taking your photo and using your photo during promotional materials for the organization / ¿Da su consentimiento a Diversity in Diabetes para tomarle fotografías y usar su imagen en materiales promocionales de la

Would you like to make a donation? / ¿Le gustaría hacer una donación?

$5

$10

$25

Signature / Firma

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