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People of Color Living with Diabetes Virtual Summit
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People of Color Living with Diabetes Virtual Summit
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First Name
Last Name
Email
Gender
-- Please Select --
Female
Male
Non-binary
Unlisted
Prefer Not to Say
City
State
Which Best Describes You?
American Indian
Asian or Pacific
Biracial
AA/Black
Hispanic
Indian
Middle Eastern
White/ Caucasian
Unlisted
Prefer Not to Say
Country/Region
Have you ever received diabetes education?
-- Please Select --
Yes
No
Prefer Not to Say
Your relationship with diabetes?
Type 2 diabetes
Type 1 diabetes
Parent/ Caregiver
Healthcare provider
LADA
MODY
Gestational Diabetes
Do not have diabetes
Prefer Not to Say
Age Range
-- Please Select --
Younger than 18
19-29
30 - 39
40 - 49
50 - 59
60 Years and older
Prefer Not to Say
Donation
-- Please Select --
$10
$25
$50
$100
$500
Other
Other Amount
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