CDC Diabetes Prevention Recognized Program Class Information Form

There are two ways to submit DPP class information; fill out the form below or download the class submission document.

Instructions:
  1. Click in each box to select an option or type information.
  2. If the DPP is canceled or rescheduled, please notify dpp@mihealthyprograms.org.
  3. Questions? Download our Frequently Asked Questions.
* Indicates required field


*Provider Organization
Please specify if "other"
Is the organization pending recognition or fully recognized by the CDC?




Provider Website
Will there be an Informational Session?




Info Session Date
Info Session Time
*First Class Date
Standard Meeting Day
Class Time (specify am/pm)

Session Location
Class Type?




Location Name
Address 1
Address 2
City
Zip
County
Location Type
Please specify if "other"

Registration/Contact Info (posted to website)
Name
Phone
Email
Registration Link
*Registration Deadline

Class Registration Submitted By (for registration questions from MDHHS)
*Name
*Phone
*Email

Other Information
Session Language (if other than English)
"Other" Notes (Payment options, special population, max # of participants, etc.)


If you would like a copy of the Registration Form for your records,
Print before clicking the Submit button.