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Welcome to the Y! We're glad to have you here. 

Please complete this form for participation in the YMCA Diabetes Prevention Program. Upon completion, the DPP Coordinator will reach out to you with next steps. 

YMCA’S DIABETES PREVENTION PROGRAM CONSENT AND RELEASE FROM LIABILITY

I hereby consent to voluntarily participate in the YMCA’s Diabetes Prevention Program. I understand that the goal of the program is to help adults at high risk of developing type 2 diabetes adopt and maintain healthy lifestyles by eating healthier, increasing physical activity, and losing a modest amount of weight to reduce their chances of developing the disease.

I understand that the YMCA does not practice medicine and the program is not a substitute for the care I receive from my physician or other qualified health care providers. I understand that the YMCA’s Diabetes Prevention Program Lifestyle Coach is not a qualified health care professional, does not practice medicine, and support provided by the Lifestyle Coach is not a substitute for the care I receive from my physician or other qualified health care providers.

In consideration for being allowed to participate in this program, I agree to assume the risk of such exercise, and further agree to hold harmless the YMCA, its employees and agents, from any and all claims, suits, losses or related causes of action for damages, including, but not limited to, such claims that may result in my injury or death, accidental or otherwise, during or arising in any way from my participation in the YMCA’s Diabetes Prevention Program.

By signing below, I affirm that I have read the above in its entirety and I understand the nature of the YMCA’s Diabetes Prevention Program. I also affirm that my questions regarding the program have been answered to my satisfaction.

 October 22, 2024 

AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION

I authorize the YMCA of Metropolitan Washington (YMCA) located at 1325 W Street NW, Suite A, Washington DC 20009 to collect and use data in connection with my participation in the YMCA’s Diabetes Prevention Program, maintain this data in a data capture system, and disclose (i.e., share) this data to the YMCA of the USA (Y-USA) located at 101 N. Wacker Drive, Chicago, IL 60606.


Data/Information to be disclosed:

  • Health information collected in connection with the YMCA’s Diabetes Prevention Program

The purposes of the disclosure include:

  • Program administration, operation, and evaluation
  • When applicable, to fulfill applicable grant reporting requirements; this may require the re-disclosure of de-identifiable and/or aggregate health information to a third-party, including government entities (e.g., the Centers for Disease Control and Prevention)

By signing below:

  • I authorize the use and disclosure of my health information as described above for the purposes indicated
  • I understand that I have the right to receive a copy of this authorization
  • I understand that the YMCA will not condition my participation in the YMCA’s Diabetes Prevention Program on my providing this authorization
  • I understand that the YMCA may receive payment or compensation (generally in the form of grants) from Y-USA, and, in some cases, such grants may condition funds on the disclosure of health information to Y-USA
  • I understand that persons or entities that receive health information under this authorization may not be bound by privacy laws (such as the federal law called HIPAA or other state data privacy laws) that protect the health information and, as such, may share it with others without my permission, if allowed by applicable law. Except as explicitly stated in this authorization, Y-USA may not further disclose my health information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law
  • I understand that I may revoke this authorization at any time by submitting my revocation in writing to the YMCA, and the revocation will not affect information that has already been used or disclosed
  • If this authorization has not been revoked, it will terminate five (5) years after your completion of your last program, unless a shorter period is specified under state law.

 

October 22, 2024 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Demographics
What sex were you assigned at birth, on your original birth certificate?*
Female
Male
Are you:*
Man
Woman
Transgender, non-binary, or another gender
I do not identify with choices provided

Please indicate your age:
Is it okay to text?*
No
Yes
What is your race or ethnicity? Select ALL that apply.*
American Indian/Alaska Native: Includes all individuals who identify with any of the original peoples of North, central, and South America. It includes people who identify as American Indian or Alaska Native.
Asian or Asian American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in East Asia, Southeast Asia, or the Indian subcontinent.
Black or African American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the Black racial groups of sub-Saharan Africa.
Hispanic or Latino: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Mexico, Puerto Rico, Cuba, Central and South American, and other Spanish cultures.
Middle Eastern or North African: Includes all individuals who identify with one or more nationalities or ethnic groups originating in the middle East or North Africa.
Native Hawaiian or Pacific Islander: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands.
White: Includes all individuals who identify with one or more nationalities in Europe.
Education Level*
Less than grade 12 (No high school diploma or GED)
Grade 12 or GED (High School graduate)
Some college or technical school
College or technical school graduate
Masters degree
Doctorate
Professional degree (MD, JD, DDS, etc.)
Other
Are you a current YMCA member?*
No
Yes
How will you pay for your participation in the YMCA's Diabetes Prevention Program? Financial assistance scholarships are made available to individuals who are unable to pay the full cost of the program.*
Self-Pay - one time payment of $429
Self Pay - 3 monthly installments of $143
Requesting 50% financial assistance - self payment of $214.50
Requesting 75% financial assistance - self payment of $107.25
Requesting 100% financial assistance

The YMCA does not directly bill private insurance companies for this program. You are encouraged to check with your provider for required documentation for any possible reimbursement.

What motivated you the most to sign up for this program?*
Health care professional
Blood test results
Prediabetes Risk Test (short survey)
Someone at the YMCA
Family or friends
Current or past participation in the program
Employer or employer's wellness plan
Health insurance plan
Media advertisements (social media, flyer, radio, etc.)
Program Champion
Did a health care professional as you to join the program?*
Yes, a doctor/doctor's office
Yes, a pharmacist
Yes, another health care professional
No

PARTICIPANT QUALIFICATIONS


Weight

Please indicate your height (2'6" to 8'2")

BMI (if you do not know, leave blank)

BLOOD VALUE/DIAGNOSIS QUALIFICATIONS

Please enter one of the four fields below. Blood values must be within the last year. 


A1c (must be 5.7% - 6.4%)

Fasting Plasma Glucose (must be 100-125 mg/dL)

2-Hour (75 gm glucola) Plasma Glucose (must be 140-199 mg/dL)
Prediabetes determined by clinical diagnoses of gestational diabetes during previous pregnancy*
Yes
No
n/a

CDC AT-RISK QUALIFICATIONS

Have you given birth to a baby weighing more than 9 pounds at birth?*
Yes
No
Do you have a parent with diabetes?*
Yes
No
Do you have a sibling with diabetes?*
Yes
No
If younger than 65 years old, do you get little or no activity in a typical day?*
Yes
No
Are you between 45 and 64 years of age?*
Yes
No
Are you 65 years of age or older?*
Yes
No

Please respond to the following questions to help us identify ways we can best assist you:
Are you deaf or do you have serious difficulty hearing?*
No
Yes
Are you blind or do you have serious difficulty seeing, even when wearing glasses?*
No
Yes
Because of a physical, mental, or emotional condition, do you have serous difficulty concentrating, remembering, or making decisions? *
No
Yes
Do you have serious difficulty walking or climbing stairs?*
No
Yes
Do you have difficulty dressing or bathing?*
No
Yes
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?*
No
Yes

Primary Care Physician Practice

If you agreed to release your protected health information with your provider, please complete the information below. 


Primary Care Physician Practice

Physician Name

Address

City

State

Zip

Phone Number

Fax Number

Email
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Demographics
What sex were you assigned at birth, on your original birth certificate?*
Female
Male
Are you:*
Man
Woman
Transgender, non-binary, or another gender
I do not identify with choices provided

Please indicate your age:
Is it okay to text?*
No
Yes
What is your race or ethnicity? Select ALL that apply.*
American Indian/Alaska Native: Includes all individuals who identify with any of the original peoples of North, central, and South America. It includes people who identify as American Indian or Alaska Native.
Asian or Asian American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in East Asia, Southeast Asia, or the Indian subcontinent.
Black or African American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the Black racial groups of sub-Saharan Africa.
Hispanic or Latino: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Mexico, Puerto Rico, Cuba, Central and South American, and other Spanish cultures.
Middle Eastern or North African: Includes all individuals who identify with one or more nationalities or ethnic groups originating in the middle East or North Africa.
Native Hawaiian or Pacific Islander: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands.
White: Includes all individuals who identify with one or more nationalities in Europe.
Education Level*
Less than grade 12 (No high school diploma or GED)
Grade 12 or GED (High School graduate)
Some college or technical school
College or technical school graduate
Masters degree
Doctorate
Professional degree (MD, JD, DDS, etc.)
Other
Are you a current YMCA member?*
No
Yes
How will you pay for your participation in the YMCA's Diabetes Prevention Program? Financial assistance scholarships are made available to individuals who are unable to pay the full cost of the program.*
Self-Pay - one time payment of $429
Self Pay - 3 monthly installments of $143
Requesting 50% financial assistance - self payment of $214.50
Requesting 75% financial assistance - self payment of $107.25
Requesting 100% financial assistance

The YMCA does not directly bill private insurance companies for this program. You are encouraged to check with your provider for required documentation for any possible reimbursement.

What motivated you the most to sign up for this program?*
Health care professional
Blood test results
Prediabetes Risk Test (short survey)
Someone at the YMCA
Family or friends
Current or past participation in the program
Employer or employer's wellness plan
Health insurance plan
Media advertisements (social media, flyer, radio, etc.)
Program Champion
Did a health care professional as you to join the program?*
Yes, a doctor/doctor's office
Yes, a pharmacist
Yes, another health care professional
No

PARTICIPANT QUALIFICATIONS


Weight

Please indicate your height (2'6" to 8'2")

BMI (if you do not know, leave blank)

BLOOD VALUE/DIAGNOSIS QUALIFICATIONS

Please enter one of the four fields below. Blood values must be within the last year. 


A1c (must be 5.7% - 6.4%)

Fasting Plasma Glucose (must be 100-125 mg/dL)

2-Hour (75 gm glucola) Plasma Glucose (must be 140-199 mg/dL)
Prediabetes determined by clinical diagnoses of gestational diabetes during previous pregnancy*
Yes
No
n/a

CDC AT-RISK QUALIFICATIONS

Have you given birth to a baby weighing more than 9 pounds at birth?*
Yes
No
Do you have a parent with diabetes?*
Yes
No
Do you have a sibling with diabetes?*
Yes
No
If younger than 65 years old, do you get little or no activity in a typical day?*
Yes
No
Are you between 45 and 64 years of age?*
Yes
No
Are you 65 years of age or older?*
Yes
No

Please respond to the following questions to help us identify ways we can best assist you:
Are you deaf or do you have serious difficulty hearing?*
No
Yes
Are you blind or do you have serious difficulty seeing, even when wearing glasses?*
No
Yes
Because of a physical, mental, or emotional condition, do you have serous difficulty concentrating, remembering, or making decisions? *
No
Yes
Do you have serious difficulty walking or climbing stairs?*
No
Yes
Do you have difficulty dressing or bathing?*
No
Yes
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?*
No
Yes

Primary Care Physician Practice

If you agreed to release your protected health information with your provider, please complete the information below. 


Primary Care Physician Practice

Physician Name

Address

City

State

Zip

Phone Number

Fax Number

Email
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Demographics
What sex were you assigned at birth, on your original birth certificate?*
Female
Male
Are you:*
Man
Woman
Transgender, non-binary, or another gender
I do not identify with choices provided

Please indicate your age:
Is it okay to text?*
No
Yes
What is your race or ethnicity? Select ALL that apply.*
American Indian/Alaska Native: Includes all individuals who identify with any of the original peoples of North, central, and South America. It includes people who identify as American Indian or Alaska Native.
Asian or Asian American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in East Asia, Southeast Asia, or the Indian subcontinent.
Black or African American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the Black racial groups of sub-Saharan Africa.
Hispanic or Latino: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Mexico, Puerto Rico, Cuba, Central and South American, and other Spanish cultures.
Middle Eastern or North African: Includes all individuals who identify with one or more nationalities or ethnic groups originating in the middle East or North Africa.
Native Hawaiian or Pacific Islander: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands.
White: Includes all individuals who identify with one or more nationalities in Europe.
Education Level*
Less than grade 12 (No high school diploma or GED)
Grade 12 or GED (High School graduate)
Some college or technical school
College or technical school graduate
Masters degree
Doctorate
Professional degree (MD, JD, DDS, etc.)
Other
Are you a current YMCA member?*
No
Yes
How will you pay for your participation in the YMCA's Diabetes Prevention Program? Financial assistance scholarships are made available to individuals who are unable to pay the full cost of the program.*
Self-Pay - one time payment of $429
Self Pay - 3 monthly installments of $143
Requesting 50% financial assistance - self payment of $214.50
Requesting 75% financial assistance - self payment of $107.25
Requesting 100% financial assistance

The YMCA does not directly bill private insurance companies for this program. You are encouraged to check with your provider for required documentation for any possible reimbursement.

What motivated you the most to sign up for this program?*
Health care professional
Blood test results
Prediabetes Risk Test (short survey)
Someone at the YMCA
Family or friends
Current or past participation in the program
Employer or employer's wellness plan
Health insurance plan
Media advertisements (social media, flyer, radio, etc.)
Program Champion
Did a health care professional as you to join the program?*
Yes, a doctor/doctor's office
Yes, a pharmacist
Yes, another health care professional
No

PARTICIPANT QUALIFICATIONS


Weight

Please indicate your height (2'6" to 8'2")

BMI (if you do not know, leave blank)

BLOOD VALUE/DIAGNOSIS QUALIFICATIONS

Please enter one of the four fields below. Blood values must be within the last year. 


A1c (must be 5.7% - 6.4%)

Fasting Plasma Glucose (must be 100-125 mg/dL)

2-Hour (75 gm glucola) Plasma Glucose (must be 140-199 mg/dL)
Prediabetes determined by clinical diagnoses of gestational diabetes during previous pregnancy*
Yes
No
n/a

CDC AT-RISK QUALIFICATIONS

Have you given birth to a baby weighing more than 9 pounds at birth?*
Yes
No
Do you have a parent with diabetes?*
Yes
No
Do you have a sibling with diabetes?*
Yes
No
If younger than 65 years old, do you get little or no activity in a typical day?*
Yes
No
Are you between 45 and 64 years of age?*
Yes
No
Are you 65 years of age or older?*
Yes
No

Please respond to the following questions to help us identify ways we can best assist you:
Are you deaf or do you have serious difficulty hearing?*
No
Yes
Are you blind or do you have serious difficulty seeing, even when wearing glasses?*
No
Yes
Because of a physical, mental, or emotional condition, do you have serous difficulty concentrating, remembering, or making decisions? *
No
Yes
Do you have serious difficulty walking or climbing stairs?*
No
Yes
Do you have difficulty dressing or bathing?*
No
Yes
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?*
No
Yes

Primary Care Physician Practice

If you agreed to release your protected health information with your provider, please complete the information below. 


Primary Care Physician Practice

Physician Name

Address

City

State

Zip

Phone Number

Fax Number

Email
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Demographics
What sex were you assigned at birth, on your original birth certificate?*
Female
Male
Are you:*
Man
Woman
Transgender, non-binary, or another gender
I do not identify with choices provided

Please indicate your age:
Is it okay to text?*
No
Yes
What is your race or ethnicity? Select ALL that apply.*
American Indian/Alaska Native: Includes all individuals who identify with any of the original peoples of North, central, and South America. It includes people who identify as American Indian or Alaska Native.
Asian or Asian American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in East Asia, Southeast Asia, or the Indian subcontinent.
Black or African American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the Black racial groups of sub-Saharan Africa.
Hispanic or Latino: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Mexico, Puerto Rico, Cuba, Central and South American, and other Spanish cultures.
Middle Eastern or North African: Includes all individuals who identify with one or more nationalities or ethnic groups originating in the middle East or North Africa.
Native Hawaiian or Pacific Islander: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands.
White: Includes all individuals who identify with one or more nationalities in Europe.
Education Level*
Less than grade 12 (No high school diploma or GED)
Grade 12 or GED (High School graduate)
Some college or technical school
College or technical school graduate
Masters degree
Doctorate
Professional degree (MD, JD, DDS, etc.)
Other
Are you a current YMCA member?*
No
Yes
How will you pay for your participation in the YMCA's Diabetes Prevention Program? Financial assistance scholarships are made available to individuals who are unable to pay the full cost of the program.*
Self-Pay - one time payment of $429
Self Pay - 3 monthly installments of $143
Requesting 50% financial assistance - self payment of $214.50
Requesting 75% financial assistance - self payment of $107.25
Requesting 100% financial assistance

The YMCA does not directly bill private insurance companies for this program. You are encouraged to check with your provider for required documentation for any possible reimbursement.

What motivated you the most to sign up for this program?*
Health care professional
Blood test results
Prediabetes Risk Test (short survey)
Someone at the YMCA
Family or friends
Current or past participation in the program
Employer or employer's wellness plan
Health insurance plan
Media advertisements (social media, flyer, radio, etc.)
Program Champion
Did a health care professional as you to join the program?*
Yes, a doctor/doctor's office
Yes, a pharmacist
Yes, another health care professional
No

PARTICIPANT QUALIFICATIONS


Weight

Please indicate your height (2'6" to 8'2")

BMI (if you do not know, leave blank)

BLOOD VALUE/DIAGNOSIS QUALIFICATIONS

Please enter one of the four fields below. Blood values must be within the last year. 


A1c (must be 5.7% - 6.4%)

Fasting Plasma Glucose (must be 100-125 mg/dL)

2-Hour (75 gm glucola) Plasma Glucose (must be 140-199 mg/dL)
Prediabetes determined by clinical diagnoses of gestational diabetes during previous pregnancy*
Yes
No
n/a

CDC AT-RISK QUALIFICATIONS

Have you given birth to a baby weighing more than 9 pounds at birth?*
Yes
No
Do you have a parent with diabetes?*
Yes
No
Do you have a sibling with diabetes?*
Yes
No
If younger than 65 years old, do you get little or no activity in a typical day?*
Yes
No
Are you between 45 and 64 years of age?*
Yes
No
Are you 65 years of age or older?*
Yes
No

Please respond to the following questions to help us identify ways we can best assist you:
Are you deaf or do you have serious difficulty hearing?*
No
Yes
Are you blind or do you have serious difficulty seeing, even when wearing glasses?*
No
Yes
Because of a physical, mental, or emotional condition, do you have serous difficulty concentrating, remembering, or making decisions? *
No
Yes
Do you have serious difficulty walking or climbing stairs?*
No
Yes
Do you have difficulty dressing or bathing?*
No
Yes
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?*
No
Yes

Primary Care Physician Practice

If you agreed to release your protected health information with your provider, please complete the information below. 


Primary Care Physician Practice

Physician Name

Address

City

State

Zip

Phone Number

Fax Number

Email
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Demographics
What sex were you assigned at birth, on your original birth certificate?*
Female
Male
Are you:*
Man
Woman
Transgender, non-binary, or another gender
I do not identify with choices provided

Please indicate your age:
Is it okay to text?*
No
Yes
What is your race or ethnicity? Select ALL that apply.*
American Indian/Alaska Native: Includes all individuals who identify with any of the original peoples of North, central, and South America. It includes people who identify as American Indian or Alaska Native.
Asian or Asian American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in East Asia, Southeast Asia, or the Indian subcontinent.
Black or African American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the Black racial groups of sub-Saharan Africa.
Hispanic or Latino: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Mexico, Puerto Rico, Cuba, Central and South American, and other Spanish cultures.
Middle Eastern or North African: Includes all individuals who identify with one or more nationalities or ethnic groups originating in the middle East or North Africa.
Native Hawaiian or Pacific Islander: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands.
White: Includes all individuals who identify with one or more nationalities in Europe.
Education Level*
Less than grade 12 (No high school diploma or GED)
Grade 12 or GED (High School graduate)
Some college or technical school
College or technical school graduate
Masters degree
Doctorate
Professional degree (MD, JD, DDS, etc.)
Other
Are you a current YMCA member?*
No
Yes
How will you pay for your participation in the YMCA's Diabetes Prevention Program? Financial assistance scholarships are made available to individuals who are unable to pay the full cost of the program.*
Self-Pay - one time payment of $429
Self Pay - 3 monthly installments of $143
Requesting 50% financial assistance - self payment of $214.50
Requesting 75% financial assistance - self payment of $107.25
Requesting 100% financial assistance

The YMCA does not directly bill private insurance companies for this program. You are encouraged to check with your provider for required documentation for any possible reimbursement.

What motivated you the most to sign up for this program?*
Health care professional
Blood test results
Prediabetes Risk Test (short survey)
Someone at the YMCA
Family or friends
Current or past participation in the program
Employer or employer's wellness plan
Health insurance plan
Media advertisements (social media, flyer, radio, etc.)
Program Champion
Did a health care professional as you to join the program?*
Yes, a doctor/doctor's office
Yes, a pharmacist
Yes, another health care professional
No

PARTICIPANT QUALIFICATIONS


Weight

Please indicate your height (2'6" to 8'2")

BMI (if you do not know, leave blank)

BLOOD VALUE/DIAGNOSIS QUALIFICATIONS

Please enter one of the four fields below. Blood values must be within the last year. 


A1c (must be 5.7% - 6.4%)

Fasting Plasma Glucose (must be 100-125 mg/dL)

2-Hour (75 gm glucola) Plasma Glucose (must be 140-199 mg/dL)
Prediabetes determined by clinical diagnoses of gestational diabetes during previous pregnancy*
Yes
No
n/a

CDC AT-RISK QUALIFICATIONS

Have you given birth to a baby weighing more than 9 pounds at birth?*
Yes
No
Do you have a parent with diabetes?*
Yes
No
Do you have a sibling with diabetes?*
Yes
No
If younger than 65 years old, do you get little or no activity in a typical day?*
Yes
No
Are you between 45 and 64 years of age?*
Yes
No
Are you 65 years of age or older?*
Yes
No

Please respond to the following questions to help us identify ways we can best assist you:
Are you deaf or do you have serious difficulty hearing?*
No
Yes
Are you blind or do you have serious difficulty seeing, even when wearing glasses?*
No
Yes
Because of a physical, mental, or emotional condition, do you have serous difficulty concentrating, remembering, or making decisions? *
No
Yes
Do you have serious difficulty walking or climbing stairs?*
No
Yes
Do you have difficulty dressing or bathing?*
No
Yes
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?*
No
Yes

Primary Care Physician Practice

If you agreed to release your protected health information with your provider, please complete the information below. 


Primary Care Physician Practice

Physician Name

Address

City

State

Zip

Phone Number

Fax Number

Email
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Demographics
What sex were you assigned at birth, on your original birth certificate?*
Female
Male
Are you:*
Man
Woman
Transgender, non-binary, or another gender
I do not identify with choices provided

Please indicate your age:
Is it okay to text?*
No
Yes
What is your race or ethnicity? Select ALL that apply.*
American Indian/Alaska Native: Includes all individuals who identify with any of the original peoples of North, central, and South America. It includes people who identify as American Indian or Alaska Native.
Asian or Asian American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in East Asia, Southeast Asia, or the Indian subcontinent.
Black or African American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the Black racial groups of sub-Saharan Africa.
Hispanic or Latino: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Mexico, Puerto Rico, Cuba, Central and South American, and other Spanish cultures.
Middle Eastern or North African: Includes all individuals who identify with one or more nationalities or ethnic groups originating in the middle East or North Africa.
Native Hawaiian or Pacific Islander: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands.
White: Includes all individuals who identify with one or more nationalities in Europe.
Education Level*
Less than grade 12 (No high school diploma or GED)
Grade 12 or GED (High School graduate)
Some college or technical school
College or technical school graduate
Masters degree
Doctorate
Professional degree (MD, JD, DDS, etc.)
Other
Are you a current YMCA member?*
No
Yes
How will you pay for your participation in the YMCA's Diabetes Prevention Program? Financial assistance scholarships are made available to individuals who are unable to pay the full cost of the program.*
Self-Pay - one time payment of $429
Self Pay - 3 monthly installments of $143
Requesting 50% financial assistance - self payment of $214.50
Requesting 75% financial assistance - self payment of $107.25
Requesting 100% financial assistance

The YMCA does not directly bill private insurance companies for this program. You are encouraged to check with your provider for required documentation for any possible reimbursement.

What motivated you the most to sign up for this program?*
Health care professional
Blood test results
Prediabetes Risk Test (short survey)
Someone at the YMCA
Family or friends
Current or past participation in the program
Employer or employer's wellness plan
Health insurance plan
Media advertisements (social media, flyer, radio, etc.)
Program Champion
Did a health care professional as you to join the program?*
Yes, a doctor/doctor's office
Yes, a pharmacist
Yes, another health care professional
No

PARTICIPANT QUALIFICATIONS


Weight

Please indicate your height (2'6" to 8'2")

BMI (if you do not know, leave blank)

BLOOD VALUE/DIAGNOSIS QUALIFICATIONS

Please enter one of the four fields below. Blood values must be within the last year. 


A1c (must be 5.7% - 6.4%)

Fasting Plasma Glucose (must be 100-125 mg/dL)

2-Hour (75 gm glucola) Plasma Glucose (must be 140-199 mg/dL)
Prediabetes determined by clinical diagnoses of gestational diabetes during previous pregnancy*
Yes
No
n/a

CDC AT-RISK QUALIFICATIONS

Have you given birth to a baby weighing more than 9 pounds at birth?*
Yes
No
Do you have a parent with diabetes?*
Yes
No
Do you have a sibling with diabetes?*
Yes
No
If younger than 65 years old, do you get little or no activity in a typical day?*
Yes
No
Are you between 45 and 64 years of age?*
Yes
No
Are you 65 years of age or older?*
Yes
No

Please respond to the following questions to help us identify ways we can best assist you:
Are you deaf or do you have serious difficulty hearing?*
No
Yes
Are you blind or do you have serious difficulty seeing, even when wearing glasses?*
No
Yes
Because of a physical, mental, or emotional condition, do you have serous difficulty concentrating, remembering, or making decisions? *
No
Yes
Do you have serious difficulty walking or climbing stairs?*
No
Yes
Do you have difficulty dressing or bathing?*
No
Yes
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?*
No
Yes

Primary Care Physician Practice

If you agreed to release your protected health information with your provider, please complete the information below. 


Primary Care Physician Practice

Physician Name

Address

City

State

Zip

Phone Number

Fax Number

Email
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Demographics
What sex were you assigned at birth, on your original birth certificate?*
Female
Male
Are you:*
Man
Woman
Transgender, non-binary, or another gender
I do not identify with choices provided

Please indicate your age:
Is it okay to text?*
No
Yes
What is your race or ethnicity? Select ALL that apply.*
American Indian/Alaska Native: Includes all individuals who identify with any of the original peoples of North, central, and South America. It includes people who identify as American Indian or Alaska Native.
Asian or Asian American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in East Asia, Southeast Asia, or the Indian subcontinent.
Black or African American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the Black racial groups of sub-Saharan Africa.
Hispanic or Latino: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Mexico, Puerto Rico, Cuba, Central and South American, and other Spanish cultures.
Middle Eastern or North African: Includes all individuals who identify with one or more nationalities or ethnic groups originating in the middle East or North Africa.
Native Hawaiian or Pacific Islander: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands.
White: Includes all individuals who identify with one or more nationalities in Europe.
Education Level*
Less than grade 12 (No high school diploma or GED)
Grade 12 or GED (High School graduate)
Some college or technical school
College or technical school graduate
Masters degree
Doctorate
Professional degree (MD, JD, DDS, etc.)
Other
Are you a current YMCA member?*
No
Yes
How will you pay for your participation in the YMCA's Diabetes Prevention Program? Financial assistance scholarships are made available to individuals who are unable to pay the full cost of the program.*
Self-Pay - one time payment of $429
Self Pay - 3 monthly installments of $143
Requesting 50% financial assistance - self payment of $214.50
Requesting 75% financial assistance - self payment of $107.25
Requesting 100% financial assistance

The YMCA does not directly bill private insurance companies for this program. You are encouraged to check with your provider for required documentation for any possible reimbursement.

What motivated you the most to sign up for this program?*
Health care professional
Blood test results
Prediabetes Risk Test (short survey)
Someone at the YMCA
Family or friends
Current or past participation in the program
Employer or employer's wellness plan
Health insurance plan
Media advertisements (social media, flyer, radio, etc.)
Program Champion
Did a health care professional as you to join the program?*
Yes, a doctor/doctor's office
Yes, a pharmacist
Yes, another health care professional
No

PARTICIPANT QUALIFICATIONS


Weight

Please indicate your height (2'6" to 8'2")

BMI (if you do not know, leave blank)

BLOOD VALUE/DIAGNOSIS QUALIFICATIONS

Please enter one of the four fields below. Blood values must be within the last year. 


A1c (must be 5.7% - 6.4%)

Fasting Plasma Glucose (must be 100-125 mg/dL)

2-Hour (75 gm glucola) Plasma Glucose (must be 140-199 mg/dL)
Prediabetes determined by clinical diagnoses of gestational diabetes during previous pregnancy*
Yes
No
n/a

CDC AT-RISK QUALIFICATIONS

Have you given birth to a baby weighing more than 9 pounds at birth?*
Yes
No
Do you have a parent with diabetes?*
Yes
No
Do you have a sibling with diabetes?*
Yes
No
If younger than 65 years old, do you get little or no activity in a typical day?*
Yes
No
Are you between 45 and 64 years of age?*
Yes
No
Are you 65 years of age or older?*
Yes
No

Please respond to the following questions to help us identify ways we can best assist you:
Are you deaf or do you have serious difficulty hearing?*
No
Yes
Are you blind or do you have serious difficulty seeing, even when wearing glasses?*
No
Yes
Because of a physical, mental, or emotional condition, do you have serous difficulty concentrating, remembering, or making decisions? *
No
Yes
Do you have serious difficulty walking or climbing stairs?*
No
Yes
Do you have difficulty dressing or bathing?*
No
Yes
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?*
No
Yes

Primary Care Physician Practice

If you agreed to release your protected health information with your provider, please complete the information below. 


Primary Care Physician Practice

Physician Name

Address

City

State

Zip

Phone Number

Fax Number

Email
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Demographics
What sex were you assigned at birth, on your original birth certificate?*
Female
Male
Are you:*
Man
Woman
Transgender, non-binary, or another gender
I do not identify with choices provided

Please indicate your age:
Is it okay to text?*
No
Yes
What is your race or ethnicity? Select ALL that apply.*
American Indian/Alaska Native: Includes all individuals who identify with any of the original peoples of North, central, and South America. It includes people who identify as American Indian or Alaska Native.
Asian or Asian American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in East Asia, Southeast Asia, or the Indian subcontinent.
Black or African American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the Black racial groups of sub-Saharan Africa.
Hispanic or Latino: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Mexico, Puerto Rico, Cuba, Central and South American, and other Spanish cultures.
Middle Eastern or North African: Includes all individuals who identify with one or more nationalities or ethnic groups originating in the middle East or North Africa.
Native Hawaiian or Pacific Islander: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands.
White: Includes all individuals who identify with one or more nationalities in Europe.
Education Level*
Less than grade 12 (No high school diploma or GED)
Grade 12 or GED (High School graduate)
Some college or technical school
College or technical school graduate
Masters degree
Doctorate
Professional degree (MD, JD, DDS, etc.)
Other
Are you a current YMCA member?*
No
Yes
How will you pay for your participation in the YMCA's Diabetes Prevention Program? Financial assistance scholarships are made available to individuals who are unable to pay the full cost of the program.*
Self-Pay - one time payment of $429
Self Pay - 3 monthly installments of $143
Requesting 50% financial assistance - self payment of $214.50
Requesting 75% financial assistance - self payment of $107.25
Requesting 100% financial assistance

The YMCA does not directly bill private insurance companies for this program. You are encouraged to check with your provider for required documentation for any possible reimbursement.

What motivated you the most to sign up for this program?*
Health care professional
Blood test results
Prediabetes Risk Test (short survey)
Someone at the YMCA
Family or friends
Current or past participation in the program
Employer or employer's wellness plan
Health insurance plan
Media advertisements (social media, flyer, radio, etc.)
Program Champion
Did a health care professional as you to join the program?*
Yes, a doctor/doctor's office
Yes, a pharmacist
Yes, another health care professional
No

PARTICIPANT QUALIFICATIONS


Weight

Please indicate your height (2'6" to 8'2")

BMI (if you do not know, leave blank)

BLOOD VALUE/DIAGNOSIS QUALIFICATIONS

Please enter one of the four fields below. Blood values must be within the last year. 


A1c (must be 5.7% - 6.4%)

Fasting Plasma Glucose (must be 100-125 mg/dL)

2-Hour (75 gm glucola) Plasma Glucose (must be 140-199 mg/dL)
Prediabetes determined by clinical diagnoses of gestational diabetes during previous pregnancy*
Yes
No
n/a

CDC AT-RISK QUALIFICATIONS

Have you given birth to a baby weighing more than 9 pounds at birth?*
Yes
No
Do you have a parent with diabetes?*
Yes
No
Do you have a sibling with diabetes?*
Yes
No
If younger than 65 years old, do you get little or no activity in a typical day?*
Yes
No
Are you between 45 and 64 years of age?*
Yes
No
Are you 65 years of age or older?*
Yes
No

Please respond to the following questions to help us identify ways we can best assist you:
Are you deaf or do you have serious difficulty hearing?*
No
Yes
Are you blind or do you have serious difficulty seeing, even when wearing glasses?*
No
Yes
Because of a physical, mental, or emotional condition, do you have serous difficulty concentrating, remembering, or making decisions? *
No
Yes
Do you have serious difficulty walking or climbing stairs?*
No
Yes
Do you have difficulty dressing or bathing?*
No
Yes
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?*
No
Yes

Primary Care Physician Practice

If you agreed to release your protected health information with your provider, please complete the information below. 


Primary Care Physician Practice

Physician Name

Address

City

State

Zip

Phone Number

Fax Number

Email
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Demographics
What sex were you assigned at birth, on your original birth certificate?*
Female
Male
Are you:*
Man
Woman
Transgender, non-binary, or another gender
I do not identify with choices provided

Please indicate your age:
Is it okay to text?*
No
Yes
What is your race or ethnicity? Select ALL that apply.*
American Indian/Alaska Native: Includes all individuals who identify with any of the original peoples of North, central, and South America. It includes people who identify as American Indian or Alaska Native.
Asian or Asian American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in East Asia, Southeast Asia, or the Indian subcontinent.
Black or African American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the Black racial groups of sub-Saharan Africa.
Hispanic or Latino: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Mexico, Puerto Rico, Cuba, Central and South American, and other Spanish cultures.
Middle Eastern or North African: Includes all individuals who identify with one or more nationalities or ethnic groups originating in the middle East or North Africa.
Native Hawaiian or Pacific Islander: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands.
White: Includes all individuals who identify with one or more nationalities in Europe.
Education Level*
Less than grade 12 (No high school diploma or GED)
Grade 12 or GED (High School graduate)
Some college or technical school
College or technical school graduate
Masters degree
Doctorate
Professional degree (MD, JD, DDS, etc.)
Other
Are you a current YMCA member?*
No
Yes
How will you pay for your participation in the YMCA's Diabetes Prevention Program? Financial assistance scholarships are made available to individuals who are unable to pay the full cost of the program.*
Self-Pay - one time payment of $429
Self Pay - 3 monthly installments of $143
Requesting 50% financial assistance - self payment of $214.50
Requesting 75% financial assistance - self payment of $107.25
Requesting 100% financial assistance

The YMCA does not directly bill private insurance companies for this program. You are encouraged to check with your provider for required documentation for any possible reimbursement.

What motivated you the most to sign up for this program?*
Health care professional
Blood test results
Prediabetes Risk Test (short survey)
Someone at the YMCA
Family or friends
Current or past participation in the program
Employer or employer's wellness plan
Health insurance plan
Media advertisements (social media, flyer, radio, etc.)
Program Champion
Did a health care professional as you to join the program?*
Yes, a doctor/doctor's office
Yes, a pharmacist
Yes, another health care professional
No

PARTICIPANT QUALIFICATIONS


Weight

Please indicate your height (2'6" to 8'2")

BMI (if you do not know, leave blank)

BLOOD VALUE/DIAGNOSIS QUALIFICATIONS

Please enter one of the four fields below. Blood values must be within the last year. 


A1c (must be 5.7% - 6.4%)

Fasting Plasma Glucose (must be 100-125 mg/dL)

2-Hour (75 gm glucola) Plasma Glucose (must be 140-199 mg/dL)
Prediabetes determined by clinical diagnoses of gestational diabetes during previous pregnancy*
Yes
No
n/a

CDC AT-RISK QUALIFICATIONS

Have you given birth to a baby weighing more than 9 pounds at birth?*
Yes
No
Do you have a parent with diabetes?*
Yes
No
Do you have a sibling with diabetes?*
Yes
No
If younger than 65 years old, do you get little or no activity in a typical day?*
Yes
No
Are you between 45 and 64 years of age?*
Yes
No
Are you 65 years of age or older?*
Yes
No

Please respond to the following questions to help us identify ways we can best assist you:
Are you deaf or do you have serious difficulty hearing?*
No
Yes
Are you blind or do you have serious difficulty seeing, even when wearing glasses?*
No
Yes
Because of a physical, mental, or emotional condition, do you have serous difficulty concentrating, remembering, or making decisions? *
No
Yes
Do you have serious difficulty walking or climbing stairs?*
No
Yes
Do you have difficulty dressing or bathing?*
No
Yes
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?*
No
Yes

Primary Care Physician Practice

If you agreed to release your protected health information with your provider, please complete the information below. 


Primary Care Physician Practice

Physician Name

Address

City

State

Zip

Phone Number

Fax Number

Email
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Demographics
What sex were you assigned at birth, on your original birth certificate?*
Female
Male
Are you:*
Man
Woman
Transgender, non-binary, or another gender
I do not identify with choices provided

Please indicate your age:
Is it okay to text?*
No
Yes
What is your race or ethnicity? Select ALL that apply.*
American Indian/Alaska Native: Includes all individuals who identify with any of the original peoples of North, central, and South America. It includes people who identify as American Indian or Alaska Native.
Asian or Asian American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in East Asia, Southeast Asia, or the Indian subcontinent.
Black or African American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the Black racial groups of sub-Saharan Africa.
Hispanic or Latino: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Mexico, Puerto Rico, Cuba, Central and South American, and other Spanish cultures.
Middle Eastern or North African: Includes all individuals who identify with one or more nationalities or ethnic groups originating in the middle East or North Africa.
Native Hawaiian or Pacific Islander: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands.
White: Includes all individuals who identify with one or more nationalities in Europe.
Education Level*
Less than grade 12 (No high school diploma or GED)
Grade 12 or GED (High School graduate)
Some college or technical school
College or technical school graduate
Masters degree
Doctorate
Professional degree (MD, JD, DDS, etc.)
Other
Are you a current YMCA member?*
No
Yes
How will you pay for your participation in the YMCA's Diabetes Prevention Program? Financial assistance scholarships are made available to individuals who are unable to pay the full cost of the program.*
Self-Pay - one time payment of $429
Self Pay - 3 monthly installments of $143
Requesting 50% financial assistance - self payment of $214.50
Requesting 75% financial assistance - self payment of $107.25
Requesting 100% financial assistance

The YMCA does not directly bill private insurance companies for this program. You are encouraged to check with your provider for required documentation for any possible reimbursement.

What motivated you the most to sign up for this program?*
Health care professional
Blood test results
Prediabetes Risk Test (short survey)
Someone at the YMCA
Family or friends
Current or past participation in the program
Employer or employer's wellness plan
Health insurance plan
Media advertisements (social media, flyer, radio, etc.)
Program Champion
Did a health care professional as you to join the program?*
Yes, a doctor/doctor's office
Yes, a pharmacist
Yes, another health care professional
No

PARTICIPANT QUALIFICATIONS


Weight

Please indicate your height (2'6" to 8'2")

BMI (if you do not know, leave blank)

BLOOD VALUE/DIAGNOSIS QUALIFICATIONS

Please enter one of the four fields below. Blood values must be within the last year. 


A1c (must be 5.7% - 6.4%)

Fasting Plasma Glucose (must be 100-125 mg/dL)

2-Hour (75 gm glucola) Plasma Glucose (must be 140-199 mg/dL)
Prediabetes determined by clinical diagnoses of gestational diabetes during previous pregnancy*
Yes
No
n/a

CDC AT-RISK QUALIFICATIONS

Have you given birth to a baby weighing more than 9 pounds at birth?*
Yes
No
Do you have a parent with diabetes?*
Yes
No
Do you have a sibling with diabetes?*
Yes
No
If younger than 65 years old, do you get little or no activity in a typical day?*
Yes
No
Are you between 45 and 64 years of age?*
Yes
No
Are you 65 years of age or older?*
Yes
No

Please respond to the following questions to help us identify ways we can best assist you:
Are you deaf or do you have serious difficulty hearing?*
No
Yes
Are you blind or do you have serious difficulty seeing, even when wearing glasses?*
No
Yes
Because of a physical, mental, or emotional condition, do you have serous difficulty concentrating, remembering, or making decisions? *
No
Yes
Do you have serious difficulty walking or climbing stairs?*
No
Yes
Do you have difficulty dressing or bathing?*
No
Yes
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?*
No
Yes

Primary Care Physician Practice

If you agreed to release your protected health information with your provider, please complete the information below. 


Primary Care Physician Practice

Physician Name

Address

City

State

Zip

Phone Number

Fax Number

Email
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Authorization to release information to Primary Care Provider
I voluntarily authorize YMCA of Metropolitan Washington (YMCA) to release or disclose my protected 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 that I have a right to receive a copy of this authorization and the information disclosed pursuant to this authorization may be redisclosed by the person(s) listed below. I understand that 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 five (5) years after your completion of your last program, unless a shorter period is specified under state law.*
No
Yes
When are you available to attend classes?
Weekends
Weekday Afternoons
Weekday Evenings
Weekends
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Demographics
What sex were you assigned at birth, on your original birth certificate?*
Female
Male
Are you:*
Man
Woman
Transgender, non-binary, or another gender
I do not identify with choices provided

Please indicate your age:
Is it okay to text?*
No
Yes
What is your race or ethnicity? Select ALL that apply.*
American Indian/Alaska Native: Includes all individuals who identify with any of the original peoples of North, central, and South America. It includes people who identify as American Indian or Alaska Native.
Asian or Asian American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in East Asia, Southeast Asia, or the Indian subcontinent.
Black or African American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the Black racial groups of sub-Saharan Africa.
Hispanic or Latino: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Mexico, Puerto Rico, Cuba, Central and South American, and other Spanish cultures.
Middle Eastern or North African: Includes all individuals who identify with one or more nationalities or ethnic groups originating in the middle East or North Africa.
Native Hawaiian or Pacific Islander: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands.
White: Includes all individuals who identify with one or more nationalities in Europe.
Education Level*
Less than grade 12 (No high school diploma or GED)
Grade 12 or GED (High School graduate)
Some college or technical school
College or technical school graduate
Masters degree
Doctorate
Professional degree (MD, JD, DDS, etc.)
Other
Are you a current YMCA member?*
No
Yes
How will you pay for your participation in the YMCA's Diabetes Prevention Program? Financial assistance scholarships are made available to individuals who are unable to pay the full cost of the program.*
Self-Pay - one time payment of $429
Self Pay - 3 monthly installments of $143
Requesting 50% financial assistance - self payment of $214.50
Requesting 75% financial assistance - self payment of $107.25
Requesting 100% financial assistance

The YMCA does not directly bill private insurance companies for this program. You are encouraged to check with your provider for required documentation for any possible reimbursement.

What motivated you the most to sign up for this program?*
Health care professional
Blood test results
Prediabetes Risk Test (short survey)
Someone at the YMCA
Family or friends
Current or past participation in the program
Employer or employer's wellness plan
Health insurance plan
Media advertisements (social media, flyer, radio, etc.)
Program Champion
Did a health care professional as you to join the program?*
Yes, a doctor/doctor's office
Yes, a pharmacist
Yes, another health care professional
No

PARTICIPANT QUALIFICATIONS


Weight

Please indicate your height (2'6" to 8'2")

BMI (if you do not know, leave blank)

BLOOD VALUE/DIAGNOSIS QUALIFICATIONS

Please enter one of the four fields below. Blood values must be within the last year. 


A1c (must be 5.7% - 6.4%)

Fasting Plasma Glucose (must be 100-125 mg/dL)

2-Hour (75 gm glucola) Plasma Glucose (must be 140-199 mg/dL)
Prediabetes determined by clinical diagnoses of gestational diabetes during previous pregnancy*
Yes
No
n/a

CDC AT-RISK QUALIFICATIONS

Have you given birth to a baby weighing more than 9 pounds at birth?*
Yes
No
Do you have a parent with diabetes?*
Yes
No
Do you have a sibling with diabetes?*
Yes
No
If younger than 65 years old, do you get little or no activity in a typical day?*
Yes
No
Are you between 45 and 64 years of age?*
Yes
No
Are you 65 years of age or older?*
Yes
No

Please respond to the following questions to help us identify ways we can best assist you:
Are you deaf or do you have serious difficulty hearing?*
No
Yes
Are you blind or do you have serious difficulty seeing, even when wearing glasses?*
No
Yes
Because of a physical, mental, or emotional condition, do you have serous difficulty concentrating, remembering, or making decisions? *
No
Yes
Do you have serious difficulty walking or climbing stairs?*
No
Yes
Do you have difficulty dressing or bathing?*
No
Yes
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?*
No
Yes

Primary Care Physician Practice

If you agreed to release your protected health information with your provider, please complete the information below. 


Primary Care Physician Practice

Physician Name

Address

City

State

Zip

Phone Number

Fax Number

Email
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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