YMCA's Diabetes Prevention Program Intake Form Step 1: Participant Details Question Title * 1. Full Name Question Title * 2. Gender Male Female Question Title * 3. Date of Birth Birthdate: Date Question Title * 4. Height Question Title * 5. Weight Question Title * 6. Ethnicity American Indian or Alaska Native Asian Black or African American Hispanic/Latino of any race Native Hawaiian or Other Pacific Islander White Question Title * 7. Is your employer / Insurer paying any portion of the fee for you to participate in the YMCA's Diabetes Prevention Program? Yes No Next