DPP Participant Pre-Registration

Your Name *

First Name Last Name

Email Address *

Used only for Program-related emails.

Daytime Phone Number *

Used only for Program-related calls.

Is it okay to leave a voice message? *

Yes No

Are you a current member of the YMCA? (For information purposes only. Membership is not required to participate in the Program.) *

Yes No

How did you hear about the Program? *

Example: My Healthcare Provider, A Family Member or Friend, My Employer

NOTE: Individuals must be confirmed eligible to participate in the Program. A 20-minute intake call is required to verify eligibility and enroll. Please provide all times that are best to reach you for a 20-minute call between Monday - Friday: *

Mornings (between 8-11 am) Afternoons (between 11 am-3 pm) Early evenings (between 3-5 pm) Late evenings (between 5-7 pm) Any time Other

Please be sure you can answer "YES" to the questions below before submitting your form for pre-registration:

I understand that to participate in the Diabetes Prevention Program individuals enrolling must be aged 18 or older, overweight and have pre-diabetes or be at high risk for type 2 diabetes (indicated by a family history of type 2 diabetes, Gestational Diabetes during previous pregnancy, or a qualifying risk score).
I understand that individuals with a current diagnosis or previous health history of type 2 diabetes do not qualify to participate in the Diabetes Prevention Program.
I understand that the Diabetes Prevention Program is a year-long program and that participants who enroll agree to attend 25 one-hour sessions over the course of 12 months (this is not a drop-in program).