Canadian Diabetes Association: Registration Form

To Life! New Registration

Please fill out the form below to register for To Life!.

Or, just call:

204-925-3800 (Winnipeg)
1-800-226-8464 (Toll-free in Manitoba)

All the information you will provide in the data fields below remain confidential, used only for the purposes of the To Life! program.

Please Note:
We are working on making the To Life! program available to people across Canada, but the program is currently only available in Manitoba. If you would like to remain in our database to receive information about program availability in your province, let us know by e-mail at info@tolife.ca. In the meantime, you can still access some program information by visiting the To Life! Kit section on our website.

1. First Name

2. Last Name

3. What age category are you in?
	Under 20
	20 to 29
	30 to 39
	40 to 49
	50 to 59
	Over 60
4. Gender
	M
	F

5. Address 1:

6. Address 2

7. City

8. Province

9. Country

10. Postal Code

11. Home Phone Number

12. Email address

13. Do you have Diabetes?
	Yes
	No
14. If yes, what type?
	1
	2
	Gestational

15. Buddy's First Name

16. Buddy's Last Name

17. Relationship with buddy:
	Friend
	Spouse
	Parent
	Child
	Sibling
	Other family member
18. What age category is your buddy in?
	Under 20
	20 to 29
	30 to 39
	40 to 49
	50 to 59
	Over 60
19. Buddy Gender:
	M
	F

20. Buddy Address 1

21. Buddy Address 2

22. Buddy City:

23. Buddy Province:

24. Buddy Country:

25. Buddy Home Phone number:

26. Buddy Postal Code:

27. Buddy Email address:

28. Overall, how healthy would you say you are at present time?
	Very Healthy
	Healthy
	Not very healthy
	Not healthy at all
	Don't know/refused
29. Does your buddy have diabetes?
	Y
	N
30. If yes, what type?
	1
	2
	Gestational
31. Would you say that the health status of your buddy is:
	better than your own.
	about the same as your own.
	or not as good as your own.
32. How would you rate your usual diet? Would you say it is generally speaking...
	Very Healthy
	Somewhat Healthy
	Not very healthy
	Not healthy at all
	Don't know/refused
33. How often do you usually exercise?
	Not at all
	Twice a month or less
	2 to 4 times a month
	1 or 2 times a week
	3 to 5 times a week
	6 times per week
	Don't know/refused

34. What do you wish to achieve while participating in the To Life! program?
	To adopt more physical activity into your daily life
	To adopt new healthy eating practices
	To adopt new healthy eating practices and increase physical activity
	Other
35. Identify how you plan to achieve this goal.

36. Where did you first hear about the To Life! program?
	TV
	Newspaper
	Billboard
	Internet
	Radio
	Friend
	Family
	Other
37. What is the highest level of formal education that you have completed?
	Did not complete high school
	High School graduate
	Some college/technical
	College/technical graduate
	Some university
	University graduate
	Post-graduate university
	Don't know/refused