2023 Application for WIN ADA’s Professional Development Course
Answers marked with a * are required.
1. Applicant name: *
2. Current Credentials: *
3. Email Address: *
4. Current Title *
5. Current Place of Employment *
6. Are you an American Diabetes Association member? *


7. Are you a member of WIN ADA? *


8. Current City and State *
9. Gender: *


10. Race: *

11. Ethnicity


12. How long have you been working in the diabetes field? *


13. How would you describe your experience level in your diabetes career? *


14. What is your primary profession? *


15. What is your primary medical specialty (or the practice you work for)? We define your primary specialty as the one in which you spend the most hours. *


16. What type of research do you conduct? *


17. What are your areas of focus in your clinic and/or research? (Select all that apply) *

18. In what tract would you want leadership training? *


19. In a few sentences, why do you feel you should be part of this program? *
20. Do you currently have a mentor who is interested in assisting you throughout the year in conjunction with this program? (Mentors are requested to meet with you once a quarter and discuss topics related to the course.) *
21. If yes, what is your mentor's name and contact information?
22. Can you commit to attending 3 virtual 2-hour long sessions throughout the year during the weekday (Monday through Friday) and 1 in-person 2-hour long session at Scientific Sessions June 2024? *


23. What topics would you like to see covered in this leadership program?