The Bahamas Diabetes Association

KIDS WITH DIABETES (KWD)

The Bahamas Diabetes Association (BDA)
APPLICATION FOR MEMBERSHIP
Annual Application Fee:

$35.00
Child’s Name
First & Last Name
Gender
Date of birth

MonthDayYear
Parent/Guardian Name (1)

First NameLast Name
Parent/Guardian Name (2)

First NameLast Name
Telephone
Primary ContactFormat: (000) 000-0000.
(Home)
(000) 000-0000
(Cell)
(000) 000-0000
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of diabetes
I am willing to serve this Association by:

Other
Would you be interested in your child being a part of the KWD Teen Group? (Grades 7-12)
Support Group
Are you interested in being a part of the KWD WhatsApp group?
Declaration: I am interested in being a member of The Bahamas Diabetes Association. I agree to abide by any Code of Conduct, professional standards or other guidance issued by BDA. By applying for membership of the BDA, I agree to abide by the standards of practice and conduct expected by the Association and will be accountable to the BDA for the breaches of those standards. I undertake
to notify the BDA of any criminal convictions, disciplinary, regulatory or other action which may be considered to bring the Association into disrepute. I agree to pay my membership fees annually.
Date

DayMonthYear
Signature of Applicant:
Should be Empty:

KIDS WITH DIABETES (KWD)