DIABETES PREVENTION PROGRAM ENROLLMENT FORM

Check for the criteria below first. If this information in unavailable, proceed to “Meets CDC At-Risk Qualifications” section, below.

Complete the questions below based on the candidate’s response only if above qualifying information is unavailable.

(BMI should be calculated using a separate resource)

Add the number of points listed.

Note: For program participation, age must be 18 years or greater (see date of birth)

I voluntarily authorize the Foothills Area YMCA to release or disclose my health information related to my participation in the YMCA's Diabetes Prevention Program to my Primary Care Physician and/or other individuals referenced below. I understand I have the right to receive a copy of this authorization and that the information disclosed pursuant to this authorization may be redisclosed by the person(s) listed below. I understand I am not required to sign this form to participate in the program, and that I may revoke this authorization at any time by submitting my revocation in writing to the YMCA. 

If this authorization has not been revoked, it will terminate in five (5) years after your completion of your last program, unless a shorter period is specified under state law.