Program Registration Form Personal Information First Name Last Name Date of Birth Gender MaleFemalePrefer not to say Address Street City State / Province ZIP / Postal Code Country Contact Information Phone Number Email Address Preferred Method of Contact PhoneEmail Emergency Contact Information First Name Last Name Relationship Phone Number Email Address Program Selection Educational Workshops Diabetes Management 101Advanced Carbohydrate CountingHealthy Cooking ClassesExercise and Fitness Support Groups General Support GroupTeen Support GroupParents Support Group Health and Wellness Programs Nutrition CounsellingFitness ProgramsStress Management Youth Programs Diabetes CampsTeen Support GroupsEducational Workshops Community Outreach Programs Free Screening EventsEducational SeminarsHealth Fairs Research and Advocacy Programs Research ParticipationAdvocacy TrainingCommunity Advocacy Availability How often are you available? Once a weekTwice a weekOnce a monthOccasionally Other Available Days and Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday Additional Information Do you have any specific goals or expectations for joining our programs? Do you have any medical conditions or dietary restrictions? YesNo If yes, please explain Are you currently under the care of a healthcare professional for diabetes? YesNo How did you hear about The Light Diabetes Organisation? WebsiteSocial MediaFriend / FamilyHealthcare Provider Other Agreement I certify that the information provided is true and I agree to participate in the programs of The Light Diabetes Organisation. Signature (Type your full name) Date
