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Mentee Application Form A
Preliminary requirements for participation:

1. You are over the age of 14.

2. You are actively working on recovering from ED-DMT1.

3. You are seeking support and encouragement to commit to better self-care.

Email address *
Last name *
Your answer
First name *
Your answer
Address (please include city, state and zip code): *
Your answer
Current age *
Your answer
Cell phone number *
Your answer
Emergency Contact Name: *
Your answer
Relationship to Emergency Contact *
Your answer
Emergency Contact cell phone and/or home phone number *
Your answer
Emergency Contact email *
Your answer
Name of your current Diabetes Care Provider *
Your answer
Clinic phone number and/or extension *
Your answer
Clinic Address *
Your answer
How long have you been working with this Provider? *
Your answer
How did you hear about the WAD Mentorship program? *
Your answer
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