Application Form We are pleased that you have decided to join INPACT — the INNODIA People Living with Type 1 Diabetes Community — and become an INPACT Associate. Please fill out this form and we will get back to you with more information and the next steps. Please also send your CV to inpact@innodia.org. Thank you — your application has been received. The INPACT team will be in touch soon. You will be redirected to innodia.org shortly. Your Details Email address * First Name * Last Name * Telephone number * Pick your country from the flag dropdown — the dial code is added automatically. About you Sex * Female Male Prefer not to say Date of birth * Date of diagnosis * If unsure, use day 1 of month 1 of the relevant year. T1D Stage I don't know / Not applicable Stage 1 Stage 2 Stage 3 Stage 4 Your clinical Type 1 Diabetes stage, if you know it. Place of birth (country) * -- Select country -- Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Central African Republic Chad Chile China Colombia Comoros Congo Congo (Democratic Republic) Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czechia Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (North) Korea (South) Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Macedonia Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Other Place of residence Country of residence * -- Select country -- Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Central African Republic Chad Chile China Colombia Comoros Congo Congo (Democratic Republic) Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czechia Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (North) Korea (South) Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Macedonia Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Other City * Postal / ZIP code * Caregiver status Are you a caregiver for a loved one with T1D? * No Parent Other caregiver If parent or caregiver, date of birth of your child or loved one with T1D Leave blank if not applicable. Spoken languages Languages you speak One language per line, in the format Language : Fluency. Allowed fluency levels: Native, Advanced, Intermediate, Basic. How you found us How did you learn about INNODIA and INPACT? Would you like to receive updates on INNODIA's activities (Symposiums, Network Events, training, "Tuesdays with INNODIA", the INNODIA Newsletter)? * Yes No Privacy The email contacts and personal data provided through this questionnaire will be included in the INNODIA database in accordance with the INNODIA — INPACT Privacy Policy — v2 and the General Data Protection Regulation (EU) 2016/679 (GDPR). By completing this questionnaire, the respondent confirms to have read and understood the INNODIA — INPACT Privacy Policy — v2 and agrees to the use of their personal data as described therein, in compliance with the GDPR. I agree to the INNODIA — INPACT Privacy Policy v2 and to the processing of my personal data as described therein. *