About YouName* First Last Are you an existing member of Diabetes Ireland?*YesNoDiabetes Ireland Membership NumberIf you are an existing member of Diabetes Ireland please enter your membership number. Contact DetailsAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone - Landline*Phone - MobileEmail Date of Birth Date Format: MM slash DD slash YYYY Type of Diabetes*Type 1Type 2PrediabetesGestational DiabetesI am a parent of a child with diabetesI don't have diabetesKeeping in Touch With YouDiabetes Ireland Magazine*As part of your Diabetes Ireland membership we will post you a copy of our Diabetes Ireland Magazine 3 times a year. I do wish to receive the Diabetes Ireland Magazine I do not wish to receive the Diabetes Ireland Magazine Keeping in Touch*As a member with us we would love to keep you updated on news, events, products & services and the different ways you can support us, including financial support. We will not provide or sell your personal data to other companies for marketing purposes. We may pass your personal data to our partners in order to process your orders and fulfill your requests. **Please note; if you have opted into receiving the Diabetes Ireland Magazine, you must opt in to 'By Post' Please tick the ways you are happy to be contacted: By email By post By phone By text message I do not wish to receive communications from Diabetes Ireland PLEASE NOTEIf you have chosen to receive the Diabetes Ireland Magazine you must opt in to receiving communication 'By Post'. The magazine is currently not available electronically. Your MembershipMembership*Please choose the membership option that suits you best.Membership & Monthly Draw (€60) (€1,000 Cash Prize Per Month)Family / Sweetpea (€45)Individual (€40)Senior / Student (€30)Health Professional (€45)DonationIf you wish to make an additional donation please select the amount you wish to donate. Every member and donation makes a difference, so please give what you can. Donation Amount€10€20€50€100Total 0,00 € PaymentIn an effort to reduce costs Diabetes Ireland is encouraging members to pay by direct debit. If you wish to pay by Direct Debit please contact 01 842 8118 Please select the payment method below that suits you best. Payment methodPayment by Credit/Debit cardDirect Debit This iframe contains the logic required to handle Ajax powered Gravity Forms.