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Diabetes Education Registration

Name

Address

Address 1

City

ZIP / Postal Code

State / Province

Country

Phone Number

What date would you prefer?

Tuesday, June 16th, 4:00-5:30 pm

Tuesday, July 7th, 4:00-5:30 pm

Tuesday, August 11th, 4:00-5:30 pm

Tuesday, September 15th, 4:00-5:30 pm

Payment Options - Cash or Checks (payable to OCAHS)

I will plan to pay $30 before the class date

I will plan to pay $30 at registration