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Diabetes Enrollment Survey August 2022

Diabetes Self Management Client Enrollment

Welcome! Please complete this form to enroll in the Diabetes Self-Management Program.

This workshop will be held on Zoom from August 18-September 29, each session will be from 1-3:30 pm.

Once you complete this form you will be enrolled in the workshop. We will contact you with workshop details when the start date approaches.

Name *This question is required.

Last
First

1. Nick name you'd like be called in class

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

Mailing Address (to send materials) *This question is required.

Address
City
Zipcode

2. Where did you hear about this workshop? *This question is required.

3. What is your date of birth? This question requires a valid date format of MM/DD/YYYY.

calendar

4. Are you_______

5. Please indicate if a healthcare provider has ever told you that you have any of the following chronic conditions:

6. What was your most recent A1C level? *This question is required.

7. What was your most recent weight? This question requires a valid number format.

pounds