Diabetes Prevention Program Enrollment Survey
Welcome! Please complete this enrollment form for the Diabetes Prevention Program. This program will be held online via Zoom.
The group will meet weekly on Mondays from 1-2PM beginning on Monday, June 19. Throughout the year, the meetings will lessen to twice a month and then monthly.
The Diabetes Prevention Program is funded by the State of Nevada/the Centers for Disease Control and Prevention. We ask that you provide information to ensure you are eligible for the program and to evaluate the effectiveness of the program. All data is encrypted and stored securely.
Name *This question is required.
This question requires a valid date format of MM/DD/YYYY.
This question requires a valid email address.
Mailing Address *This question is required.
Please continue on and complete eligibility information.
This question requires a valid number format.
13. What is your height? (This is a qualifier question for you to enroll in this program) *This question is required.