Registration Form

Diabetes Patient Tele-Education Program Registration: 2021

The registration form is to be filled in and submitted by the program facilitator at participating sites. If you plan to participate in the session from home, you are not required to complete the form. However, you are welcome to provide us with you contact information on the form so that we can send you reminder messages. Thank you.
  • Please fill out the following registration form to participate in our programs.

  • (hospital, health department, community health center, etc. Those participating may provide their name and address)
  • (hospital, health department, community health center, etc.) If you are not registering more than 1 site, please leave blank.
  • (if participating from home, please enter N/A)
  • Please include contact information.
  • Please select the tele-education program(s) your site would like to participate for April 2021. All classes are from 1:00-2:30pm. 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 June 2021. All classes are from 1:00-2:30pm. Press and hold down the COMMAND/ALT key and click on the sites to make multiple selections.
  • *All classes are scheduled from 1:00-2:30 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.