Diabetes Prevention Participant Enrollment Form

This document was created and adapted by DTTAC for use by organizations delivering the National Diabetes Prevention Program. For assistance with completing this form, please contact one of our Lifestyle Coaches below.

  • Male
    Female
  • American Indian or Alaska Native
    Asian
    Black or African American
    Native Hawaiian or Other Pacific Islander
    White
  • Hispanic or Latino
    Not Hispanic or Latino
  • Less than grade 12 (no high school or GED)
    Grade 12 or GED (High school graduate)
    Some College (1 year - 3 years)
    College (4 years or more)
  • Yes
    No
  • Employee
    Student
    Retiree
    Spouse on Health Plan
    Non-affiliated
  • Security Captcha: *
  • 229.219.3191
  • Campus Address
    Student Health Center 
    2nd Floor. Admin Suite
    1500 N. Patterson St.
    Valdosta, Georgia 31698
  • Mailing Address
    1500 N. Patterson St.
    Valdosta, GA 31698