DPP Participant Pre-Registration

Thank you for your interest in YMCA’s Diabetes Prevention Program. Please complete the form below and one of our YMCA Program Staff will contact you directly to explain more about the Program, confirm your eligibility and discuss options for participation / enrollment.
Your Name*

First NameLast Name
Email Address*
Used only for Program-related emails.
Daytime Phone Number*
Used only for Program-related calls.Format: (000) 000-0000.
What is your preferred spoken language?*

EnglishSpanishCantoneseOther
Is it okay to leave a voice message?*

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

YesNo
Do you identify with any of the following organizations or institutions?*

I'm an employee or retiree of the City and County of San FranciscoI'm a patient at UCSF Zuckerberg General HospitalI'm a member of San Francisco Health PlanI'm a member of Health Plan of San MateoI do not identify with any of these groups
How did you hear about the Program?*
Example: My Healthcare Provider, A Family Member or Friend, My Employer, YMCA website
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 timeOther
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).
Should be Empty: