Program Registration Form Personal Information First Name Last Name Date of Birth Gender Address Street City State/Province ZIP/Postal Code Country Contact Information Phone Number Email Address Preferred Method of Contact PhoneEmail Emergency Contact First Name Last Name Relationship Phone Number Email Address Program Selection Diabetes Management 101Advanced Carbohydrate CountingHealthy Cooking ClassesExercise and FitnessGeneral Support GroupTeen Support GroupParents Support GroupNutrition CounsellingFitness ProgramsStress ManagementDiabetes CampsEducational WorkshopsFree Screening EventsEducational SeminarsHealth FairsResearch ParticipationAdvocacy TrainingCommunity Advocacy Availability Once a weekTwice a weekOnce a monthOccasionally Other Availability Weekly Schedule Additional Information Goals / Expectations Medical Conditions YesNo If Yes, Explain Under healthcare professional? YesNo How did you hear about us? WebsiteSocial MediaFriend/FamilyHealthcare Provider Agreement I confirm that the information provided is accurate. Signature Date
