Become a Member

Thank you for your interest in membership to the Diabetes Foundation of Mississippi, Inc. It is our hope that you will choose to join the DFM and grow with us during the upcoming year. The Diabetes Foundation of Mississippi is dedicated to caring for all Mississippians who live with diabetes– from our children to our seniors. We continue to fund research, patient assistance, quality up-to-date diabetes education and blood-glucose screenings statewide. We also offer care to newly diagnosed children to provide them with a healthy start to their new lives with diabetes. In addition, we also value our adults and seniors by insuring that they have the best of care to enhance their quality of life while living with diabetes for years to come.

If you would like to join us in our fight against diabetes, and receive membership benefits, including a subscription to Diabetes Self-Management and In Touch, fill out the form below.

* Indicates required field.

Levels of Membership:

Charter: $25.00

Benefits:
Diabetes Self-Management, In Touch, Medic Alert Card, Free brochures

Contributor: $50.00

Benefits:
Carbohydrate Counting, Plus Charter benefits

Sponsor: $100.00

Benefits:
Nutrition Action, Plus Contributor benefits

Your Information

1. Title --- Select a title --- Mr. Mrs. Ms Miss Dr.
2. First Name *
3. Middle Initial
4. Last Name *
5. Address 1 *
6. Address 2
7. City *
8. State --- Select a state --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *
9. Zip Code *
10. Phone 1
11. Phone 2
12. Email *
13.  

Membership Information

1. Membership Type Charter Member Contributor Sponsor *
2.  

Payment Information

1. Credit Card Visa Mastercard American Express *
2. Credit Card Number *
3. Expiration Date Month: -- 01 02 03 04 05 06 07 08 09 10 11 12   Year: ---- 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 *
4.  

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