Diabetes Prevention Program (DPP) Consent/Contract Form

If you have any questions completing this form please contact us at 1-800-928-4416 EXT 1158
First Name*
Last Name*
Date of Birth*
Month
Day
Year
Sex:*
- Female
- Male
Race:*
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Other Pacific Islander
- White
Ethnicity:*
- Hispanic or Latino
- Not Hispanci or Latino
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Email*
Enter Email Confirm Email
Height:*
I voluntarily agree to participate in the Diabetes Prevention Program (DPP)
through the Lake Cumberland District Health Department (LCDHD). I understand that I may code 1 hour per session that I attend as long as I maintain 75% attendance of all sessions. I have received my supervisor's permission to participate in the Life Change Program. (Attendance will be maintained by the Lifestyle Coach.) I also acknowledge that I have been provided a copy of the LCDHD Notice of Privacy Practices.
Date*
MM slash DD slash YYYY

I voluntarily agree to participate in the Diabetes Prevention Program (DPP)