*1.What is your name?(Required.)

2.What is the best phone number to reach you?

3.What is the best time of day to reach you?

Morning

Afternoon

Evening

4.Is English your first language?

Yes

No

5.How did you hear about the class?

Doctor Referral

Department of Health

Diabetes class or support group

Family member or friend

Saw a flyer in the community

Other (please specify)