Language
English (US)
Spanish (Latin America)
Type Zero Foundation Membership
Creating everyday support for families with diabetes in Central FL
Dear New Family,
Welcome home! Once you fill out this application, a volunteer will reach out to schedule a Zoom call to meet you and provide any resources that you need. After that, you're welcome to utilize all of the services our volunteers have put together for our families impacted by diabetes. We look forward to getting to know you and supporting you on your health and wellness journey. You are not alone!
Your Name
*
First Name
Last Name
Best Email to Send Resources & Updates
*
example@example.com
Your Phone Number
*
Format: (000) 000-0000.
Residence Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Total Number of Family Members Registering for Membership
*
Please Select
1
2
3
4
5
6
Type of diabetes you/your family need support for
*
Type 1 diabetes
Type 2 diabetes
Gestational diabetes
LADA
MODY
Other
Approximately when did the first diagnosis take place?
*
-
Month
-
Day
Year
Date
Most immediate needs
*
Access to diabetes medications
Access to health insurance
Diabetes education
Diabetes support
Financial assistance for housing, food, etc.
Other
Which free support services would interest you and your family?
*
Dance & sport classes through income sliding scale (available to children 4yrs+ and adults)
Parent yoga classes
Moms/Grandmas/Caregivers small group
Dads/Grandpas/Caregivers small group
Young adult small group
Dia-Elf Project visit (surprise home visit at Christmas from elf with diabetes)
Member events (Diabetes Ninja Night, weekend retreat, Day at Fun Spot amusement park, etc.)
Volunteering and helping other new families
Let us know if you or any family members have other needs. We will connect you with members who have these in common with you:
Youth autism/neurodivergence
Adult autism/neurodivergence
Other autoimmune disease(s)
Name/Age/Interests of Family Members with Diabetes
*
Who referred you to us?
*
Please Select
My doctor/nurse
Facebook
Google search
A volunteer
Enroll
Should be Empty: