2025 National Diabetes Prevention Program (NDPP) Interest Form

According to the CDC, more than 88 million American adults have prediabetes. This is challenging to take in, but the facts state that, “1 in 3 US adults” have prediabetes. It could be you, your favorite brother, or your other brother who has prediabetes, and they do not know it.

This is your time to change your life, improve your health, and prevent your risk of Type 2 diabetes.

We will begin our new cohort August 2025. Your time is NOW!

Please complete our NDPP Interest Form below, to take charge of your health and prevent your risk of type 2 diabetes.
(CDC, 2021).

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Name (Required.)

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Email (Required.)

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Home Address? (Required.)

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Phone (Required.)

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Best Time to Call (Required.)

Morning (8:00 am - 11:00 am)

Afternoon (11:00 am - 4:00 pm)

Evening (4:00 pm - 6:00 pm)

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Date of Birth: (Required.)

Date / Time

Date

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Gender (Required.)

Female

Male

Non-binary

Prefer not to say

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Height?

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Weight?

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Please select your ethnicity (Check all that apply) (Required.)

American Indian and Alaska Native

Asian

Native Hawaiian or other Pacific Islander

Black/African American

Hispanic/Latino/a/x

White (non-Hispanic)

Other

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Insurance Information. Please select your type of insurance and medical plan? (Required.)

Medicare

Medi-Cal

Private Insurance

Other (please specify)

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Medical Plan (Choose one) (Required.)

IEHP

Molina Healthcare

Kaiser

Other (please specify)

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Diabetic History. Have you previously been diagnosed with Type 1 or Type 2 diabetes? (Required.)

Yes

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Diabetic History. Have you previously been diagnosed with prediabetes? (Required.)

Yes

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Diabetic History. Is your A1c between 5.7% and 6.4%? (Required.)

Yes

Not sure

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Prediabetes Risk Test Score (1-5)

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What time of day works best for you? (Required.)

Morning

Afternoon

Evening

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Have you participated in NDPP before? (Required.)

Yes

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How did you hear about this program? (Required.)

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Media Release: The Riverside Community Health Foundation (RCHF) have my permission to use my photograph/video publicly to promote NDPP. I understand that the images/audio may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use. (Required.)

I agree

I do not agree

2025 National Diabetes Prevention Program (NDPP) Interest Form

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* Name (Required.)

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* Email (Required.)

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* Home Address? (Required.)

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* Phone (Required.)

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* Best Time to Call (Required.)

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* Date of Birth: (Required.)

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* Gender (Required.)

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* Height?

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* Weight?

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* Please select your ethnicity (Check all that apply) (Required.)

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* Insurance Information. Please select your type of insurance and medical plan? (Required.)

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* Medical Plan (Choose one) (Required.)

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* Diabetic History. Have you previously been diagnosed with Type 1 or Type 2 diabetes? (Required.)

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* Diabetic History. Have you previously been diagnosed with prediabetes? (Required.)

Question Title

* Diabetic History. Is your A1c between 5.7% and 6.4%? (Required.)

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* Prediabetes Risk Test Score (1-5)

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* What time of day works best for you? (Required.)

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* Have you participated in NDPP before? (Required.)

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* How did you hear about this program? (Required.)

Question Title

Name (Required.)

Email (Required.)

Home Address? (Required.)

Phone (Required.)

Best Time to Call (Required.)

Date of Birth: (Required.)

Gender (Required.)

Height?

Weight?

Please select your ethnicity (Check all that apply) (Required.)

Insurance Information. Please select your type of insurance and medical plan? (Required.)

Medical Plan (Choose one) (Required.)

Diabetic History. Have you previously been diagnosed with Type 1 or Type 2 diabetes? (Required.)

Diabetic History. Have you previously been diagnosed with prediabetes? (Required.)

Diabetic History. Is your A1c between 5.7% and 6.4%? (Required.)

Prediabetes Risk Test Score (1-5)

What time of day works best for you? (Required.)

Have you participated in NDPP before? (Required.)

How did you hear about this program? (Required.)