Diabetes Registration

Class will be held October 20th and 27th, November 3rd and 10th 5:30-7:30 p.m. and located at Montgomery County Health Department. Light refreshments will be available.

Please use the side door entrance near the handicap accessibility ramp to enter the building and follow signs to classroom. Classroom is located on the 1st floor near the Montgomery County Health Department Clinic.

For additional information or questions, please call Michelle Hill at 859-497-2448.

Confirmation Number

Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Telephone #

Hidden

Birth Date(Required)

MM slash DD slash YYYY

Hidden

How long have you lived with diabetes?(Required)

Recently diagnosed

Less than 1 year

Less than 5 years

More than 5 years

I do not have diabetes but want to learn more

Hidden

What are you interested in learning about diabetes?(Required)

How would you like to receive class reminders or updates?(Required)

(Check all that apply)

Phone Call

Text

Or any of the above

Hidden

Can we leave a message?(Required)

Yes

How did you hear about this class?

Medical Provider

Newspaper or Radio

Health Dept website

Facebook

Family or Friend

Other

Additional information: . If you are experiencing cold, COVID or flu like symptoms, we ask that you not attend until symptoms are gone. Face Masks are not required but encouraged.

Schedule Date(Required)

If you are experiencing cold, COVID or flu like symptoms, we ask that you not attend until symptoms are gone. Face Masks are not required but encouraged.