Strong Spirit, Strong Heart
Hello and Welcome to Native Americans for Community Action (NACA) Health Promotions 8 - Week Diabetes Prevention Program.
Our Diabetes Prevention Program uses the CDC recognized lifestyle change program Prevent T2. Throughout this program you will be able to gain knowledge in managing, preventing, and delaying Type 2 Diabetes. Each session we will explore different tools to optimize Your Wellness through healthy eating, physical activity, and stress management.

Our classes are held every week on Wednesdays from 5:30-6:30 pacific time.

Contact the Wellness Center for any further questions (928)773-1245, ext. 221 or email us at hpwc@nacainc.org.
Sign in to Google to save your progress. Learn more
Full Name (First, Last) *
Which cohort are you signing up for? *
Email  *
Date of Birth *
Ethnicity *
Required
Gender *
Phone Number
Mailing Address (City, State, ZIP code) *
Emergency Contact- Name(Relationship) and Phone Number  *
Would you like to be contacted regarding future NACA Health Promotion Events? *
Required
Are you a NACA Patient?  *
Required
Do you have a history of any of the following:  *
Required
How Did You Hear about our Event? Please check one box. *
Required
What do you wish to learn or hope to achieve by the end of the 8 week health education series? Please share yours thoughts, goals and interests here.  *
I hereby release and agree to hold NACA Wellness Center harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of NACA Wellness Center, or that may otherwise arise in any way in connection with any services received from NACA Wellness Center. I understand that this release discharges NACA Wellness Center from any liability or claim that I, my heirs, or any personal representatives may have against NACA Wellness Center with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from NACA Wellness Center. This liability waiver and release extends to NACA Wellness Center with all owners, partners, and employees. IF YOU AGREE TO THE ABOVE STATEMENT,  SIGN YOUR NAME BELOW: *
The NACA Marketing Officer will be taking photographs at the event. These photos will only be used for NACA Marketing purposes. If you do not want to be included in any photographs, please let us know below. Do you give consent for NACA to use your likeness in photographic marketing material?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Native Americans for Community Action Inc.. Report Abuse