*1.What is your name?(Required.)

*2.What is the name of the organization you represent?(Required.)

*3.What is your email address?(Required.)

*4.What geographic area(s) of North Carolina do you serve?(Required.)

*5.Are you applying to be a member or collaborator?(Required.)

Member: NCDAC members are voting participants committed to active engagement. Expectations include attending at least two of three annual meetings, voting on council matters, joining a subcommittee or initiative, and mentoring new members. Members should also communicate affiliation changes, advocate for diabetes awareness, and support health equity efforts.

Collaborator: Individual(s) or organizations supporting NCDAC’s mission to reduce the burden of diabetes in NC. They may attend meetings, join subcommittees, and participate in initiatives but do not have voting rights or term limits.

*6.What areas of expertise can you contribute to the DAC? (ex: hearing/audiometry, endocrinology, DSMES, etc.).(Required.)

*7.Is your organization involved in diabetes prevention or management programs? Select all that apply(Required.)

Involved in National DPP

Involved in DSMES Program

Involved in diabetes prevention activities (other than DPP or DSMES)

Involved in diabetes management activities (other than DPP or DSMES)

None of the above 

N/A

*8.What is your current role at your organization? (Required.)

*9.Why are you interested in joining the DAC?(Required.)

*10.How do you see yourself contributing to the DAC?(Required.)

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