Lifestyle Change Programs – Workshop Registration "*" indicates required fields Today's Date:* MM slash DD slash YYYY Which program are you interested in Attending? (Check One):* Diabetes Prevention Program-Prevent T2 Your Diabetes, Your Heart Active Living After Cancer Hypertension Workshops Blood Pressure Management Name:* First Last Address:* City/ State:* Zip code:* Phone:*Email:* Contact preference:* Phone Mail Email Gender:* Male Female Other Date of Birth MM slash DD slash YYYY Ethnicity (select one):* Hispanic Non-Hispanic Race (select all that apply):* African American/Black American Indian/Alaskan Native Asian Native Hawaiian/Another Pacific Islander White Highest level of education earned:* Less than High School High School Graduate Some College College Graduate or more Preferred Language:* English Spanish Weight - lbs.* Height - Ft* Height - Inches* Date of most recent blood pressure reading:* MM slash DD slash YYYY Most recent blood pressure reading:Systolic:* Diastolic:* Are you currently taking blood pressure medication?* Yes No Don't Know Have you been diagnosed with cardiovascular disease?* Yes No Don't Know Do you currently smoke?* Yes No Don't know Have you been diagnosed with high cholesterol?* Yes No Don't know Have you been diagnosed with kidney disease?* Yes No Don't know Have you been diagnosed with Type 2 Diabetes?* Yes No Don't know Have you been diagnosed with prediabetes?* Yes No Don't know Are you a cancer survivor?* Yes No Don't know If yes, are you currently undergoing treatment for cancer (chemotherapy or radiation)?* Yes No Don't know Are you caregiver for anyone suffering from cancer?* Yes No Don't know Additional Comments:Media Consent FormPlease download the Media Consent Form, sign and scan (or take a photo) and upload the signed photocopy of the form. (You may also email the consent form to *protected email*)Signed Consent File to uploadAccepted file types: jpeg, jpg, gif, pdf, png, Max. file size: 1 MB.CAPTCHANumber