Join Our Community

Become a Member

This intake form helps BIDSI provide the right support and resources to each of its members.

Personal Information

First name *

Last name *

Email address *

Phone number *

Address *

Gender *

Male

Female

Diabetes Information

Are you living with diabetes? *

Current diabetes management strategies / medicine

Do you have any known medical conditions? If yes, specify.

How Did You Hear About Us?

Referral source *

Emergency Contact Information

Contact name *

Relationship *

Phone number *

Preferences & Additional Information

I would like to receive communications from BIDSI regarding diabetes-related events, networking opportunities, news, and educational resources.

Additional information (optional)

Membership Agreement

I agree to become a member of the BIDSI diabetic community. I further agree to keep my membership status in good standing by paying the annual membership of $25. I understand that my information will be kept confidential and used solely for the purpose of providing support and resources.

Yes, I agree to the membership agreement