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AADA Individual Membership Application Form
AADA Individual Membership Application Form
FIRST STEP
• Complete and submit the Membership Application (below).
SECOND STEP
• Once notified by AADA of your acceptance, you will be requested to submit you annual dues.
* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Street Address
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
County
*
Your answer
State
*
Your answer
Business Email Address
*
Your answer
Personal Email
*
Your answer
Office Phone
*
Your answer
Cell Phone
*
Your answer
How did you hear about AADA?
Your answer
What is your experience with diabetes?
*
Your answer
Ethnic Background
*
Black/African American
American Indian or Alaska Native
Hispanic or Latino
Native Hawaiian or other Pacific Islander
Asian
White
African - Ghana, Liberia, Kenyan, Nigerian, Somalian, etc.
Biracial
Caribbean Islander of African Descent
Decline this survey question
Are you affiliated with any other health advocacy organizations? If yes, Please describe your involvement.
*
Your answer
Membership Level Requested.
*
Student High School/College or University $25.00 Annual
Regular Bronze Member $50.00 Annual
Silver Member and Sponsor $125.00 Annual
Gold Member and Sponsor $250.00 Annual
Diamond Member and Executive Sponsor $1,000 - $10,000 Annual
Required
I acknowledge that I have read the AADA Individual Membership Application and accept the outlined responsibilities of a AADA Members as outlined on the AADA website.
Type your full name (First Name/Last Name) below as your signature
*
Your answer
Send me a copy of my responses.
Submit
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