Registration Form

Registration Form

2015 Diabetes Patient Tele-Education Programs

(Required)
(Required)
(hospital, health department, community health center, etc.)
(Required)
(Required)
(Required)
When you hit the SUBMIT button, this form is automatically emailed to the program director.
Please check the tele-education program(s) your site would like to participate in for 2015. All classes are from 1:00 - 3:00 pm.
It is helpful for us to know in advance about your interest in participating in the educational programs. If you are uncertain about your schedule for the entire year, you may sign up for educational programs on a per program basis.
When you hit the SUBMIT button, this form is automatically emailed to the program director and registrars.