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Eatwell... and Prevent Diabetes
Prevent Diabetes Culinary Program
Please complete the questionnaire below to qualify for an upcoming class.
Name
Birthday
Email
Address
Phone
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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