Registration for Virtual DIABETES Self-Management Workshop Series
Carroll County Division of Aging & Disabilities provides at NO COST the Evidence-Based Living Healthy, Living Well Program. Living Healthy, Living Well is a suite of self-management workshop series originally developed at Stanford University for those with Chronic Disease, Diabetes and Chronic Pain. Living Healthy, Living Well meets for 2 1/2 hours a week for six weeks. For more information visit our website at https://carrollcountymd.gov/livinghealthy, email livinghealthy@carrollcountymd.gov or call 410-386-3800.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Emergency Contact Name
*
In case of an emergency who would you like us to contact? This would be if you were having some type of emergency event on screen or if you stepped away from the camera on your electronic device and did not return. We reserve the right to contact 911 if necessary.
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Will you need a tablet as part of our tablet loan program?
Yes
No
How did you hear about our workshops and mailed tool kits?
*
Referral
Web search (Google, Microsoft Edge, etc.)
Flyer or Brochure
Living Healthy, Living Well Website
Social Media
Carroll Hospital Calendar
Division of Aging & Disabilities
Carroll County Government Press Release/Email
Carroll County Health Department
Aging Your Way Expo
Senior and Community Center
WTTR
Church
Publication
Other
Age
*
60 +
Under 60
Submit
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