Membership Application Form
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Account Information |
| Desired Username |
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| Desired Password: |
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Your Information |
| First Name: |
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| Last Name: |
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| Credentials: |
MD, PhD, etc. |
| Employer: |
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| Job Title: |
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| Areas of Expertise: |
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| Email Address: |
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| Alt. Email Address: |
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| Telephone: |
Ext:
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| Alt. Telephone: |
Ext:
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| Fax: |
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| Alt. Fax: |
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| Mailing Address: |
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| Address Cont: |
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| City: |
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| State: |
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| Zip: |
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Type of Membership: Check the appropriate box based upon your anticipated involvement with the DCC
Active Membership: Individuals who commit to active participation in one or more committees, and attendance at twice-yearly DCC meetings.
Associate Membership: Individuals who are not able or do not wish to perform the responsibilities of active membership, but who wish to be updated on committee activities and contribute to DCC business on an ad hoc basis.
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Active Member:
Associate Member:
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Individual Member or Organization Representative: |
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Organizational Representative:
Individual:
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Individuals who are accepted for membership as a representative of their organization please complete the following: |
| Organization: |
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Specify the type of organization you are representing (Check all appropriate boxes.):
Academic
Hospital
Community practice or clinic
Non-profit community
Funding Agency
Legislative
Diabetes service or product
Government agency
Media Health care system/ insurance company
Other
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Short Answer Questions:
1.Describe your reason(s) for wanting to join the Diabetes Coalition of California (DCC). (500 characters max)
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2. For Organization Representatives only :
Indicate what your organization is doing to reduce the burden of diabetes in California (i.e. programs, funding, activity evaluations, etc.). Please Note: It is the prospective member’s responsibility to communicate membership acceptance and subsequent DCC activities back to their organization. (500 characters max)
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Characters Remaining:
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Committee Participation Preference: If you are applying for Active Membership, review the enclosed committee descriptions and rank your committee preferences as 1st, 2nd, and 3rd. Committee assignments will consider individual interest and expertise, as well as DCC needs. Use a 0 if you don't want to participate in that particular committee
Advocacy Committee
Education Committee
Guidelines Committee |
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