12th Annual Diabetes in the Limelight Jamboree (Virtual)

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Event Timing: Saturday 7th November, 2020; 4 p.m Trinidad & Tobago Time (Check your time zone)

Contact us at:
Website: https://www.bovellcancerdiabetesfoundation.org
Email: bovellcancerdiabetesfoundation@gmail.com
Phone number: 1-868-667-2576
WhatsApp: 1-334-590-3073
Facebook: https://www.facebook.com/bovellcancerdi1/

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REGISTRATION FORM

DIABETES EDUCATION MAKES THE DIFFERENCE!

Name *

Address *

Home Phone:

Cell Phone: *

Gender: *

Female

Male

Prefer not to say

Drugo:

Age Range: *

<15 years

15-25 years

26-35 years

36-46 years

47-50 years

51-66 years

67-77 years

>77 years

Obvezno

Education: (completed one or more of the following) *

Primary School

High School (Secondary School)

Professional School ( Teacher's College, Nursing, Police, Agricultural, Technical school etc.)

Trade School

University

University+

N/A (Not Applicable)

Obvezno

Medical History: (in the family) *

Diabetes

High Blood Pressure

Heart Disease

Kidney Disease

Stroke

Cancer

Drugo:

Obvezno

When was your last visit to a doctor? *

When was your last visit to a dentist? *

When was your last visit to an eye doctor? *

When was the last time you had a foot exam? *

First Time Jamboree Attendee *

Yes

Will you be willing to receive messages from BCDF? *

Yes

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