YDPP Preregistration Form - YMCA of Central Stark County

Registration Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Gender*

MaleFemale
Height*
Weight*
Ethnicity*
YMCA of Central Stark County Branch*
Preferred Time*

DayEvening
Has your doctor diagnosed you as:
Choose one*

Pre-diabeticDiabeticI'm Not Sure
Lab Values/Diagnosis
Choose One*

AC1Fasting Plasma GlucoseOther - Risk Assessment
A1C (must be 5.7 – 6.4)
Fasting Plasma Glucose (must be 100-125, Medicare 110-125)
CDC Risk Score
Insurance
Insurance
Are you an OhioHealth associate?*

YesNo
Clock #:*
Do you have a spouse that works for OhioHealth?*

YesNo
Clock #:
Who is the primary insurance cardholder?*

YouSpouse
Insurance coverage not required to enroll
Private pay options and financial assistance available for those who qualify.
Other:*
Medicare Type*
Medicare Claim Number*
Medicare Advantage*
Other Medicare Advantage*
How did you hear about the program?*
Level of Education*
Marital Status*
Income Level*
Does candidate's income meet federal poverty guidelines for income status?*

YesNo
Do you have end stage renal disease?*

YesNo
Individual Plan Number*
Group Number*
Employee Clock Number*
Should be Empty:

Registration Form