Rye YMCA Diabetes Prevention Program Checklist

YMCA's Diabetes Prevention Program Checklist
In order to qualify for the YMCA’s Diabetes Prevention Program, you must be overweight with a Body Mass Index (BMI) of 25 or greater and at high risk for developing type 2 diabetes or have been diagnosed with prediabetes. Not sure what your BMI is? Click here to calculate your BMI. Please answer the questions below to determine if you are at risk for developing diabetes.
DO YOU MEET THE PROGRAM REQUIREMENTS? Please check each box that is true.
DO YOU HAVE ONE OF THE FOLLOWING LAB VALUES OR DIAGNOSIS? Please check each box that is true.
If you checked a box above, enter value.
Full Name

First NameLast Name
Birth Date

MonthDayYear
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Mobile Phone

Area CodePhone Number
Height and Weight

HeightWeight
Race/Ethnicity
Is your employer/insurer paying any portion of the fee for you to participate in the YMCA's Diabetes Prevention Program?
HOW DID YOU HEAR ABOUT THE YMCA"S DIABETES PREVENTION PROGRAM? Please check the box that applies.
For more information or questions, contact Heidy Barros, Community Health Coordinator, at 914-967-6363, ext. 114
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YMCA's Diabetes Prevention Program Checklist