We want you as a member of the Hot Diabetic Club.

Please answer a few questions to be considered for a scholarship membership.

First Name

Last Name

Email *

Phone *

Are you a diabetic? *

Please provide a monetary amount that you can contribute each month. Be specific for a higher chance of approval. *

Additional information about you that could help our team offer you the best support. Are you a student, in a transition period of your life, etc.? *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.