Maryland Diabetes Patient and Family Caregiver Virtual Forum Registration

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Please note that we are now accepting registrations for our WAITING LIST. You will receive a Zoom confirmation email if we are able to accommodate you.

Thank you for your interest in attending the Maryland Diabetes Patient and Family Caregiver Virtual Forum on Saturday 2/12/22 from 1:00-3:30 pm. This event is hosted by the Maryland Diabetes Patient and Family Caregiver Advisory Group and sponsored by the Maryland Department of Health.

Please note that in addition to receiving valuable information about diabetes, the forum will include small group discussions where participants will have the opportunity to share about their lived experiences. In order to ensure a meaningful experience, attendance will be limited and registration is required. After completing this registration form you will receive an email with additional information. If you have questions, feel free to reach out to the coordinator, Dr. Nicole Rochester, by sending an email to info@yourgpsdoc.com.

Email *

Full Name *

I understand that this is a virtual event and I am comfortable participating in this virtual forum using the Zoom platform *

Phone number (optional) *By providing your phone number, you consent to receiving text message reminders about this event. Charges may apply.

Age *

18-25

26-35

36-45

46-55

56-65

>65

I live in Maryland: *

Yes

I live in ___ County *

I am a: *

Patient with diabetes

Patient with prediabetes

Family member caring for someone with diabetes or prediabetes

Required

What is your race/ethnicity? *

American Indian or Alaskan Native

Asian

Black or African-American (non-Hispanic)

Hispanic or Latino

Native Hawaiian or Pacific Islander

White (non-Hispanic)

Race/ethnicity not listed here

I prefer not to answer this question

How did you hear about this event?

Healthcare provider/Clinic/Diabetes educator

Community or Religious organization

Friend/Family member/Co-worker

Social media

Radio

Other

Please click the link to view the consent form. Please note that all attendees are REQUIRED to consent to participating in this forum. https://docs.google.com/document/d/1GtJlML83KZCZ22CVbxIRHZ4oRLd71fHa/edit?usp=sharing&ouid=117301012368562821776&rtpof=true&sd=true *

I have read the attached consent form in its entirety. I attest that I am 18 years of age or older and I agree to participate in the virtual forum. (Please be sure to also type your name in the next question, below.)

Required

If you prefer to review a copy of the registration form in a language other than English, please choose from the list below. You will need to copy and paste the URL into your browser. (*Please note that the live forum will be in English only.)

If you prefer to review a copy of the consent form in a language other than English, please choose from the list below. You will need to copy and paste the URL into your browser. (*Please note that the live forum will be in English only.)

My typed name below serves as my signature and confirmation of my consent to participate in the forum. *

I am willing to complete a survey after the event to share my experience and provide feedback *

Yes

A copy of your responses will be emailed to the address you provided.

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