MiniMed Ambassador Application

Ambassador application

Joining the community can include, but isn’t limited to:

Attending local events to discuss your journey with diabetes.
Direct contact with MiniMed, making sure your voice is heard! This may include providing survey feedback to help influence future products and programs.
Branded Champion items to help express yourself.
Recognition of milestones, including your dia-versary!
Participation in new social media campaigns.
Potential to be featured in marketing or customer story highlights.

We can’t wait to have you as part of our #MiniMedChampion Community!

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Contact information

First name

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Last name

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U.S. ZIP code

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Phone

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We’d like to celebrate your diaversary. Please share with us the date you were diagnosed.

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We’d like to celebrate your diaversary. Please share with us the date you were diagnosed.

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We’d like to celebrate your diaversary. Please share with us the date you were diagnosed.

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We’d like to celebrate your diaversary. Please share with us the date you were diagnosed.

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Specify other

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Are you a MiniMed employee?*

Yes No

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Are you a healthcare provider and/or work in a healthcare professional environment?*

Yes No

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What is your occupation?

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Please briefly describe your history with diabetes in the space below. (i.e., diagnosis story, how old you were, type of diabetes, products used since then, etc.).

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Other, please specify

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We’d love to get to know you. Please share links to your social media channels so we can get a sense for who you are.

Personal blog or website URL

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X (formerly Twitter)

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Facebook

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YouTube

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TikTok

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Instagram

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Other social

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Briefly tell us, in the space below, how you’re involved with your local diabetes community. (Examples: support groups, attending organization events, etc.)

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Please share any thoughts regarding your personal relationship with/connection to Medtronic in the space below and why you choose to use Medtronic products.

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Please tell us why you would like to be a part of the #MiniMedChampion community.

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Please specify other areas

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What activities/goals would you hope to accomplish as part of the program?

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Address

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City

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State

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U.S. Zip Code

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By checking this box, I authorize Medtronic MiniMed, Inc. (“Medtronic Diabetes”) to access and use my/my dependent’s, as applicable, protected health information or personally identifiable information, solely for the purpose of confirming my status as a Medtronic Diabetes customer/my use of Medtronic Diabetes products in connection with my application to the MiniMed Champion. This authorization will expire: (a) at the conclusion of the purpose above or (b) after the maximum amount of time permitted by applicable law, whichever occurs first. I understand this authorization is voluntary and that I may refuse to sign it. My refusal to sign this authorization will not affect my ability to obtain Medtronic Diabetes products and services, other treatment, or receive payment of or my eligibility for benefits.

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If I am a Medtronic employee, I acknowledge that my participation is completely voluntary, and I understand that any information I provide here will be kept in a secure location and will not be shared with my manager, Human Resources, or anyone else in a position to impact my job at Medtronic.

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Thank you!

We’ve received your request – we’ll be in touch with product information soon.

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Application questions