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.

Question Title

* 1. Contact Information

First Name *

Last Name

Address *

Address 2

City *

State

ZIP/Postal Code *

Email Address *

Phone Number *

Question Title

* 2. I am...

an individual interested in a program

an organization interested in delivering a program

Other (please specify)

Question Title

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

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)

Question Title

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

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

Question Title

* 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)