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Eatwell......And Prevent Disease
Heritage to Health Culinary Program
Please complete the questionnaire below to qualify for an upcoming class.
Name
Email
Phone
Birthday
Address
Do you have a family history of Diabetes?
*
Yes
No
Have you ever been diagnosed with any of the following?
*
Pre-Diabetes
Type 1 Diabetes
Type 2 Diabetes
None of the Above
Please select your ethnicty
*
African American/Black
Asian American
Hispanic/ Latin American
Native American
Other
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