2024 Diabetes Prevention Program Registration

Whitney Wellness Workshop DPP Registration
The National Diabetes Prevention Program (National DPP) is a Centers for Disease Control and Prevention (CDC)-led, proven lifestyle change program that can help people with pre-diabetes cut their risk of developing type 2 diabetes in half. A trained lifestyle coach works with participants to teach lifestyle skills needed to make lasting changes, such as eating healthier, adding physical activity, and managing stress.
The goal of this year-long program is for participants to lose 5 to 7 percent of their body weight and gain 150 minutes of weekly physical activity. Program participants meet weekly for 16 weeks over an initial six-month period, and monthly over the next six months.
Today's Date

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Date
Name*

First NameLast Name
Address*

Street Address

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CityState / Province

Postal / Zip Code
County
Email
example@example.com
Phone Number*
I would like to register for the following workshop time:*
Age/Date of Birth*
How would you describe yourself? Please select all that apply. (This is voluntary, we use this information for grant-reporting purposes.)

African-American/BlackAmerican-Indian/Alaskan Native/Native HawaiianAsianCaucasian/WhiteImmigrant/Foreign Born U.S. CitizenLGBTQ+Veteran
All participants must have audio and visual technology capabilities. This could be a smartphone, laptop, or tablet with a camera and microphone. Details will be emailed to participants once they have registered prior to the class start date. The Whitney Senior Center will contact participants to practice using Zoom and to provide support for technology challenges prior to the start of the class. Through a grant, Whitney Senior Center is able to loan out technology for class participation. Please contact the Wellness Coordinator at 320-650-3082 for more information.
How did you hear about the workshop? (select all that apply)

Non-Primary Healthcare ProfessionalPrimary Care ProviderCommunity OrganizationFamily/FriendsEmployee Wellness ProgramInsurance CompanyMediaFacebookThe Bright Side of 50Whitney ConnectionsLetter from CentraCareMyChart NotificationEssentia/Crow Wing EnergizeCommunity Calendar (SC Times, MN Monthly, Around the Cloud)Other
Do you allow Whitney Senior Center to share your attendance records with your CentraCare provider and/or your Essentia/Crow Wing Energize provider?

YesNo
Do you qualify for Medicare?

YesNo
If you do qualify for Medicare, what supplemental insurance do you have? _____________________________________________________________________________
Do you want to use your Medicare benefit for your participation in this Diabetes Prevention Program? If yes, you can disregard the Cost Share schedule (suggested donation chart) below.

YesNo
The privacy of your health information is important to the Whitney Senior Center and is mandated by law. As a participant in Whitney Senior Center Wellness Workshops, both you and the other participants may discuss medical information in the presence of other participants, family members, staff, and Lifestyle Coaches. By signing below, you are agreeing to and authorizing the discussion of your personal medical information in the workshop group setting. Your signature also means that you will respect the confidentiality of the other members of the group by not revealing medical or any other identifying information after the session is over. Your signature also means that you will not hold the City of Saint Cloud, Whitney Senior Center nor any of the officers or employees of either responsible for any breach of confidentiality committed by other patients in the group.
I UNDERSTAND AND AGREE WITH THIS STATEMENT OF CONFIDENTIALITY.
Please type your name as an electronic signature.
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Whitney Wellness Workshop DPP Registration