Diabetes Wellness Connection

Native American Diabetes Project Registration

Native American Diabetes Project
Registration

We would like to know who finds the "Strong in Body and Spirit" Curriculum helpful. We also hope you will let us know if you print and adapt the curriculum for your tribe by sending electronically or printing and faxing us a copy of this registration form. Also, we would appreciate a copy of any significant revisions or publications originating from this work.

While we are providing the curriculum free to you through the Internet, we ask that you take a minute to fill out the following information.

Name:

Address:

Phone: Fax:

Email:

Tribal Affiliation or Organization:

Position:
Patient
Health Educator
PA or FNP
Nutritionist
Nurse
Physician
Tribal Leader
Psychologist
Other

Do you intend to adapt the curriculum for your community? Yes No

In what setting do you plan to use the curriculum?
Home
Tribal Offices
Clinic
Senior Center
Other

Who will teach the sessions?

Are you interested in obtaining the Teacher Module to go with the curriculum? Yes No

Do you wish to attend a "Team Training" Session?
Would you be able to travel to Albuquerque for training? 		Yes No
Yes No

Print and fax to:
  Office of Native American Diabetes Programs
University of New Mexico/Department of Internal Medicine
1720 Louisiana Blvd., NE, Suite 312
Albuquerque, New Mexico 87110
Telephone No. (505) 272-8465vwolfe@salud.unm.edu