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DPP Interest Form
This form indicated that you are interested in learning more about the Diabetes Prevention Program. You will get an email from angela.deal@maryland.gov with instructions on how to register. Feel free to call, 301-609-6622 if you have any questions.
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Phone Number
*
Your answer
Mailing Address
*
Your answer
City, State
*
Your answer
Which class do you want to register for?
*
IN-PERSON, 5/22/24, 6pm-7pm
Date of Birth
*
MM
/
DD
/
YYYY
What is your current A1C (it is ok to skip this question if you are not sure)?
Your answer
Gender
*
Your answer
Where did you hear about this program?
*
Medical Provider
Postcard received in the mail
Southern Maryland Newspaper
Mobile ad
Facebook
Friend/Family
Other:
Are you committed to participating in a full year of classes and support?
*
Yes
No
Do you have prediabetes?
*
Yes
No
I am not sure
I believe I am at risk for prediabetes
Do you have a Support Person/Caregiver that will participate with you?
Yes
No
Name and Relation to You:
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