Diabetes Class Sign Up Form

WE WILL EMAIL YOU OUR LIST OF UPCOMING CLASS AND WALK YOU THROUGH SIGNING UP FOR THE CLASS YOU’RE INTERESTED IN
JOIN THE EMAIL LIST TO HEAR ABOUT OTHER UPCOMING CLASSES AND OFFERINGS
NOW THAT WE HAVE YOUR INFORMATION, SIGNING UP FOR FUTURE CLASSES WILL BE A BREEZE!

Name

Please use the name of the person with prediabetes or diabetes

First Name

Last Name

Are you completing this form for yourself or someone else?

Myself

I am a spouse

I am a parent

I am a caregiver

I am a family member

How old is the individual with prediabetes or diabetes?

Phone

(###)

###

####

Email

Do you have any questions for us?

Please check the box below to certify you understand these classes are $35 per person per class and are able to pay this amount.

I understand and accept

Where and When are the classes?

All classes are in person at our office located in Columbia, MO

Bamboo Nutrition: 1905 Cherry Hill Dr. Ste 300 Columbia, MO 65203

Handicap access is located on the backside of the building.

Dates and Times for the classes are TBD.