School Walk for Diabetes: School Walk for Diabetes Thanks You

Thanks for your interest in School Walk for Diabetes!

Simply complete the following form and we'll take care of the rest! Your participation in this event would strengthen the fund-raising efforts of the American Diabetes Association (ADA) as we strive to prevent and cure diabetes, which currently affects more than 23.6 million Americans. You will receive more information in the mail and your local School Walk coordinator will be in touch with you soon.

Contact Information

Name:

Title	First Required	Middle Required	Last Required	Suffix

E-mail: Required

Question - Required - School Name

Question - Required - School's Address

Question - Not Required - Address 2

Question - Required - City

Question - Required - State

Question - Required - Zip Code

Question - Required - School Phone #

Question - Not Required - School FAX #

Question - Not Required - Alternate Contact Number

Question - Required - Your role at school

Question - Not Required - Principal's Name (if not yourself)

Question - Required - School District

Question - Required - My school primarily represents the following grade level range: Elementary school (K-6)
Middle School (7-8)
High School (9-12)
Elementary-Middle (K-8)
Elementary-High (K-12)

Question - Not Required - When would you like to have your School Walk for Diabetes? The exact day you select is flexible.

Month

Day

Year

Question - Not Required - What is the maximum number of students that might participate in your School Walk for Diabetes?

Question - Not Required - What is the fund-raising goal for your school?

Question - Required - What is the best time to contact you? (ex. 9:00AM)

Question - Required - What is the best way to contact you about School Walk for Diabetes? Phone (School Number)
Phone (Alternate Number)
E-mail
U.S. Mail

How did you hear about School Walk for Diabetes?

(Select one of the available choices or enter a different value.)
Question - Not Required -


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