To Life! = Vive la Vie!: Registration Form

Please fill out the form below to renew your To Life! registration.
Or, just call:

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

Note: renewals will not be accepted after
February 5, 2003.

1. Did the To Life! program help you to achieve the healthy active living goal you identified when you registered?
	Yes
	No
2. Would you like to receive more information from the Canadian Diabetes Association?
	Yes
	No

3. What part of the To Life! Kit was the most useful to you?

Buddy #1

5. Name

6. Address

7. Address 2:

8. City

9. Province

10. Country

11. Postal Code

12. Telephone

13. E-mail Address

14. Household Income
	$0 - $30,000
	$30,001 - $40,000
	$40,001 - $60,000
	$60,001 - $80,000
	$80,000+
Buddy #2

16. Name:

17. Address

18. Address 2:

19. City

20. Province:

21. Country:

22. Postal Code

23. E-mail Address

24. Household Income
	$0 - $30,000
	$30,001 - $40,000
	$40,001 - $60,000
	$60,001 - $80,000
	$80,000+

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.