DPAC Member Information Form

New Member Information Form

Please submit your information by filling in the fields below.

* Are required fields.

* First Name:

* Last Name:

Title:

Credentials:

* Organization:

* Address:

Address 2:

* City:

* State:

* Zip:

* Phone:

Fax:

* Email:

* Organization Sector – Please choose at least one that best describes your affiliation or organization.

DPAC Workgroup and Committees – Please choose only one that you plan to participate in at the next full membership meeting.

Workgroup/Committee

Purpose

Communication/Public Awareness Workgroup

Increase public awareness and improve DPAC internal communication.

Advocacy/Policy Workgroup

Advocate for people with diabetes; address health disparities and access to care issues.

Training and Education Programs Workgroup

Improve and promote culturally relevant and sensitive diabetes education services and care.

Prevention Workgroup

Expand diabetes primary prevention activities.

Data/Research Workgroup

Identify and enhance available data systems; support other DPAC workgroups' data needs.

I agree to join DPAC, to endorse the DPAC membership expectations, and to promote the mission of DPAC. I also give permission to include my name on written materials or web sites as a supporter of DPAC.

Please read the paragraph above and click the check box in order to Submit your membership information.

Write to info@dpacmi.org with any membership questions.