Registration Form

Diabetes Patient Tele-Education Program Registration: 2020

The registration form is to be filled in and submitted by the program facilitator at participating sites. Thank you.
  • Please fill out the following registration form to participate in our programs. When you hit the SUBMIT button, the form is automatically emailed to the program director.

  • (hospital, health department, community health center, etc.)
  • (hospital, health department, community health center, etc.) If you are not registering more than 1 site, please leave blank.
  • Please include contact information.
  • Please select the tele-education program(s) your site would like to participate for April 2020. All classes are from 1:00-3:00pm. Press and hold down the COMMAND/ALT key and click on the sites to make multiple selections.
  • Please select the tele-education program(s) your site would like to participate for October 2020. All classes are from 1:00-3:00pm. Press and hold down the COMMAND/ALT key and click on the sites to make multiple selections.
  • *All classes are scheduled from 1:00-3:00 pm

  • Confirmation of Registration

    After submitting the form, you will receive a registration confirmation. The confirmation includes a link to the Facilitator Resource page, please follow the link and take note of the URL. Before facilitating the program, please print out the resources that you will need for the program. Thank you.