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Participant Interest Form

Please complete this form if you are interested in learning more information about HPCs Make a Choice Programs. By completing this form you are consenting to being contacted by a member of the HPC team to follow up on your interest in one or more of our programs.

*1.Contact Information(Required.)

First Name *

Last Name

Address *

Address 2

City *

State

ZIP/Postal Code *

Email Address *

Phone Number *

*2.I am...(Required.)

an individual interested in a program

an organization interested in delivering a program

Other (please specify)

*3.Which program(s) would you like to learn more about?(Required.)

Diabetes Prevention Program (Prediabetes)

Diabetes Self-Management

Chronic Disease Self-Management

Chronic Pain Self-Management

Walk with Ease (Arthritis)

Caregivers Chronic Disease Self-Management

Blood Pressure Self-Monitoring Program

Medical Nutrition Therapy (MNT)

Diabetes Self-Management Education and Support (DSMES)

Other (please specify)

*4.How would you like a program to be delivered?(Required.)

In-Person

Online/Virtual via Zoom

Online/Virtual at own pace (not via Zoom)

Telephone Conference Calls

Self-Directed (Do program at your own speed)

No Preference

5.How did you hear about Health Promotion Council programs? Check all that apply

Community Organization

Medical Provider

Word of Mouth

Internet Search

Social Media

Website

Other (please specify)

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