Health Department Registration Form

Free Diabetes Classes on the Road Outreach Program

If you wish to register for free diabetes classes, please complete the following form. Seating is limited and registration is required.

Registrants should be age 18 years and over diagnosed with diabetes, or family members and/or care givers to those diagnosed with diabetes.

You will receive a follow-up phone call and/or e-mail to confirm your registration.

All fields are required.

General Information
Last Name:  
First Name:  
MI:  
Date of Birth: (MM/DD/YYYY) 
Age:    
Email:    
Address:  
City:  
State:  
Zip:    
Daytime Phone Number:  
Evening Phone Number:  

Emergency Contact
Name of Emergency Contact:  
Relationship to Registrant:  
Contact Daytime Phone Number:  

Select a Desired Class
1st Choice   2nd Choice