Instructions:  Please complete the following form and click on the "Submit your booking" button at the bottom.
If you have quesion please Contact us

First Name *

Last Name *

Gender * Select ... Female Male Intersex Trans – Female to Male Trans – Male to Female Two-spirit Prefer not to answer Do not know Other

Other Gender

Address *

City/Town *

Email *

Post Code *

Phone *

Age * Select ... under 20 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+

Ethnicity Select ... Caucasian/White Black or African American East Asian Native American or American Indian Hispanic or Latino Middle Eastern South Asian Other (please specify below)

Other Ethinicty

Highest Education Level Completed Post-secondary (College/University)
Primary (Grades 1-8)
Secondary (Grades 9-13)
No formal schooling
Do not know
Prefer not to answer

Why are you attending * I am attending because I have diabetes
I am attending to help someone else with their diabetes

Which topics are relevant to you? (Please select all that apply) * Asthma
Arthritis
Emphysema, COPD or other Lung Disease
Cancer
Diabetes
Heart Disease
High Blood Pressure
Osteoporosis
Other(Please specify below)

Other Relevant Topics

How did you hear about the workshop? *

Guidelines for Participation in this one time workshop In order to benefit from this workshop, we ask you to:

• Come to the session as registered
• Take care of your needs (stand up, stretch, leave the room)
• Make S.M.A.R.T goals based on the content delivered
• Be respectful of others and their ideas
• Maintain confidentiality
• Turn off your cell phones/pagers
• Participate in group discussion

I have read and agreed to the guidelines for participation. *

Informed consent
I grant permission to Choose Health-Toronto Central, c/o South Riverdale Community Health Centre:

1. To contact me in the future for the purposes of providing self management related updates, such as additional programming, events, training, and research opportunities.
2. To share de-identified information collected in the workshop with external partners for the purpose of ongoing evaluation and quality improvement of the program.
3. To request responses via email, if applicable, to evaluation tools.

Check here to confirm. *

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