Diabetes Prevention Program
Participant Interest Information
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I am... *
Name *
Email *
Phone Number *
Zip Code *
Have you taken the pre-diabetes risk test? *
If so what was your score?  If not follow link to take test and provide score below. https://www.cdc.gov/diabetes/takethetest/ *
Do you know your A1C? If so, what is it most recently? *
Preferred mode of class instruction/participation (select all that apply) *
Required
Available days and times for class  (select all that apply)
This information helps us place you in a class that fits into your schedule!
Tuesday
Thursday
10 am
2pm
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