Diabetes PATH Workshop

Register Participants

Required fields are indicated with an asterisk (*)

Name & Address

* First Name

* Last Name

* Address

Addt'l Address

* City

* County

* State

* Zipcode

* Phone Number

* E-mail If you supply an e-mail address, a receipt for your registration will automatically be sent to that account. An e-mail address is required to pay using a credit card.

Emergency Contact Information In case of an emergency, please provide an emergency contact person we can call if you show signs of an emergency.

* First Name

* Last Name

* Phone Number

Registration Information

* I would like to register for this Diabetes PATH Series

* I agree to have my video and audio enabled during the program.

I prefer my participant workbook in the following format * Hard Copy E-book (electronic)

* Age

Contact Information

For more information or questions, contact Jacqui Rabine at Rabineja@msu.edu or 248-930-4125.