October 2021 Diabetes Management Series Registration Form

October Diabetes Management Series Registration Form

The Diabetes Management Series will be held ONLINE on Tuesdays, October 19, 26, and November 2nd, 2021 from 1-2 p.m.

After registering, you will receive an email with instructions on how to access the class.

The email address you provide below will only be used to send instructions on how to join the class. We will also send you one reminder before each class if you answer "Yes" to question 6.

1. First Name: *This question is required.

2. Last Name: *This question is required.

Phone Number: (xxx-xxx-xxxx)

*This question is required.

How did you hear about our classes?

Newspaper
Workplace
Television/News
Facebook/Twitter
Word of mouth
Doctor's office (please list name in space below)
Other (please specify): Please enter an 'other' value for this selection.

5. E-mail address:

(Please note: We will send access to the online class to the email you provide) *This question is required.

6. I would like to receive reminders about future diabetes management events.