Sign up for Chronic Disease and/or Diabetes Self-Management workshops
1.
Name:
2.
Phone number:
3.
Email Address:
Both Chronic Disease Self-Management and Diabetes Self Management classes have two ways we can teach the class. One-hour class is a shorter, more condensed version of the 2.5 hour class. Both versions of the class are for 6 sessions for 6 weeks.
4.
Class you like to sign up for: Chronic Disease Self-Management Workshop (for people with chronic disease or a caregiver, 6 week long class) and/or Diabetes Self-Management Workshop (diabetics, pre-diabetes and caregivers, 6 week long class).
Yes
No
Would like more information
Chronic Disease Self-Management Workshop
Yes
No
Would like more information
Diabetes Self-Management Workshop
Yes
No
Would like more information
5.
We offer an one hour by classes for Chronic Disease Self-Management Workshop and Diabetes Self-Management Workshop. What day of the week works best for you?
Monday
Tuesday
Wednesday
Thursday
Friday
Other (please specify):
6.
What time(s) works best for the one hour classes Chronic Disease Self-Management Workshop and/or Diabetes Self-Management Workshop?
9 am to 10 am
10 am to 11 am
11 am to noon
Noon to 1 pm
1 pm to 2 pm
2 pm to 3 pm
3 pm to 4 pm
4 pm to 5 pm
5 pm to 6 pm
6 pm to 7 pm
7 pm to 8 pm,
Other (please specify)
7.
We offer 2.5 hour classes for Chronic Disease Self-Management Workshop and Diabetes Self-Management Workshop. What day(s) of the week works best for you?
Monday
Tuesday
Wednesday
Thursday
Other (please specify):
8.
What time(s) works best for the 2.5 hour Chronic Disease Self-Management Workshop and/or Diabetes Self-Management Workshop.
Morning (between 9 am and Noon)
Afternoon (Between 1:30 pm and 5 pm)
Evening (starting at or after 5 pm
Other (please specify)
Current Progress,
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