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Diabetes Coalition of Palm Beach County
Diabetes Coalition of Palm Beach County
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  • Home
  • About Us
    • Our Story, Mission & Vision
    • Diabetes Coalition Initiatives
    • The Alarming Impact of Diabetes
    • Strategic Plan
    • By-laws
    • Our Leadership Team – Board of Directors
  • Volunteer
  • Data
  • Resources
  • Why Join?
    • Why Join?
    • New Member – Renewal Application
    • Pay Annual Membership Dues
    • Member Scholarship Application
    • Committees – Opportunities to Contribute
  • Events
    • Event Calendar
    • Know Your Numbers Diabetes Prevention Screening Campaign (Featured Event)
    • Diabetes Awareness Day
      (Featured Event)
    • Past Event Highlights
  • Sponsors
    • Join Our Cause
    • Thank You To Our Funders & Sponsoring Partners
    • Become A Donor
    • Know Your Numbers Sponsor Form
    • A Tribue To Barbara Jacobowitz
  • Donate

Diabetes Month 2016 Screening Site Participation Form

  • Yes, we would like to participate in Diabetes Week 2016 by providing a Screening Site Venue for free Diabetes Risk Assessments and Glucose Screenings.

    Please Note: Although the Coalition will be doing activities during the entire month of November, we have designated Saturday, November 12th through Saturday, November 19th as the primary week for screenings.

    If you are doing multiple (separate) site locations, please complete a separate form for each site.

  • Diabetes Screening Site Contact Information

  • All fields on the form must be completed.

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • Contact for Screening Site and Volunteer Coordination

    * if different from above

  • Screening Services to be Offered

  • If multiple days, please indicate # for each day
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • If yes, what languages

  • Glucose Screenings

  • (If you are doing multiple days, please provide Total Number of Participants for all of the days.)

  • Diabetes Screening Site Materials

  • Remember, if you are doing multiple site locations, please complete a separate form for each site.

    How many ADA Risk Assessment Forms will you need?

    If you are doing multiple days, please provide total number for all of the days. Please note: the same number of “Know Your Number Cards” will be included.

  • Please note: If you are providing educational items or promotional items, please have them delivered to Kaiser University by Wednesday, October 21, 2016. Please contact Debby Walters, Executive Director, to set up an appointment for delivery and for more details debby.diabetescoalitionpbc@gmail.com

    Remember, if you are doing multiple site locations, please complete a separate form for each site.

CONTACT US

info@diabetescoalitionpbc.org

2051 MLK Jr. Blvd. Suite 306
Riviera Beach, FL 33404

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