Virtual Lifestyle Change Program

Registration Form

Intertribal Wellness Lifestyle Change Program: Prevent Type 2 Diabetes Program
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
TextEmailPhone callEither option
African AmericanAmerican IndianAsianHawaiianWhite
Birth date*

MonthDayYear
Date
YesNo
YesNo
YesNo
YesNo
Referred by: blanks
YesNo
Diabetes Risk Test
What did you score?
YesNo
If so, what is your latest Hemoglobin A1C (HbA1c) reading?
What is your current weight?*
What is your height?*
YesNoNot sure
Date of Diagnosis Date
YesNo
YesNo
SamsungGarminAppleFit BitWithingsOther
CignaBlue Cross Blue ShieldMountain Health Co-opMedicaidMedicareUninsuredOther
Other: blanks
Some Elementary, Middle or High SchoolHigh School Graduate or GEDSome College or Technical SchoolFour Year College Degree
YesNo
All information will be confidential and only shared with authorized CDC representatives for the National Diabetes Prevention Program.
Date

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Registration Form