Juntos Por Una Vida Saludable (Prevención de la Diabetes Tipo 2)

Juntos Por Una Vida Saludable (Prevención de la Diabetes Tipo 2)

Together For a Healthy Life! Preventing Diabetes Type 2
Full Name/ Nombre completo*

First NameLast Name
Phone Number/Número de teléfono*
Please enter a valid phone number.
Email*
example@example.com
Fecha de nacimiento*

MonthDayYear
Mes - Dia - Año
Zip Code/ Codico Postal*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender (declared at birth)/Género declarado al nacer*

Female/FemeninoMale/Masculino
Have you been diagnosed with pre-diabetes in the past?/¿Ha sido diagnosticado con pre-diabetes?*

YesNo
Please select your age range/ Por favor, seleccione el rango de edad.*

Less than 40 years40 - 49 Years50 - 59 Years60 Years or older
Have you ever been diagnosed with gestational diabetes?/¿Alguna vez ha sido diagnosticado con diabetes gestacional?*

YesNo
Do you have a mother, father, sister or brother with diabetes?/¿Tiene una madre, padre, hermana o hermano diagnosticado con diabetes?*

YesNo
Have you ever been diagnosed with high blood pressure?/¿Alguna vez ha sido diagnosticado con presión arterial alta?*

YesNo
Are you physically active?/¿Es usted físicamente activo?*

YesNo
Race/Raza*

Mixed Race/MestizoNative American/Indio americanoAsian/AsiáticoAfrican American/AfroamericanoWhite/BlancoUnknown/DesconocidoPrefer not to Disclose/No quiero declararNative Hawaiian or Pacific Islander/Nativo de Hawai u otra isla del Pacífico
Ethnicity/Etnicidad*

Hispanic or Latino/ Hispano o LatinoNot Hispanic or Latino/ Ni hispano ni latinoPrefer not to answer/ Prefiero no contestar
Language preference / Idioma de preferencia*

EnglishEspañol
Height/Altura*
Si solo sabes tu peso y estatura en el sistema metrico haz click aqui:

Ingresar mi peso y estatura en Kg. y cm
Weight category - 4' 10"*

119 - 142143 - 190191 +Less than 119
Weight category - 4'11"*

124 - 147148 - 197199 +Less than 124
Weight category - 5'0"*

128 - 152148 - 197204 +Less than 128
Weight category - 5'1"*

132 - 157158 - 210211 +Less than 132
Weight category - 5'2"*

136 - 163164- 217218 +Less than 136
Weight category - 5'3"*

141 - 168164- 217218 +Less than 136
Weight category - 5'4"*

145 - 173174 - 231232 +Less than 145
Weight category - 5'5"*

150 - 179180 - 239240 +Less than 150
Weight category - 5'6"*

155 - 185186 - 246247+Less than 155
Weight category - 5'7"*

159 - 190191 - 254255+Less than 159
Weight category - 5'8"*

164 - 196197 - 261262+Less than 164
Weight category - 5'9"*

169 - 202203 - 269270+Less than 169
Weight category - 5'10"*

174 - 208209 - 277278+Less than 174
Weight category - 5'11"*

179 - 214215 - 285286+Less than 179
Weight category - 6'0"*

184 - 220221 - 293294+Less than 184
Weight category - 6'1"*

189 - 226227 - 301302+Less than 189
Weight category - 6'2"*

194 - 232233 - 310311+Less than 194
Weight category - 6'3"*

200 - 239240 - 318319+Less than 200
Weight category - 6'4"*

205 - 245246 - 327328Less than 205
Enter your weight / Ingresa tu peso*
Kg
Enter your height / Ingresa tu altura*
Cm
Calculation
Preferred schedule*

MondayThursday
Available on Mondays:*

MorningAfternoon
Available on Thursday:*

AfternoonEvening
How did you find out about this new program?*

Participante de Juntos por una vida saludableWord of Mouth (Family & friends)LAA Coffee HourLAA internal referralInstagramFacebookLinkedInTwitterGoogle searchLAA WebsiteTV/RadioEmailExternal referralPrint advertisingSchool, collegeGovernment Agency
Name of the person that referred you to the program*
Email of the person that referred you to the program
example@example.com
Phone Number of the person that referred you to the program*
Please enter a valid phone number.
By registering for our upcoming event, you and all of the individuals listed, grant the Latin American Association (LAA) and its partners permission to use any photographs or media captured during the event for promotional and marketing purposes. Your participation signifies consent, and you release all rights to these images./ Al registrarse para nuestro próximo evento, usted y todas las personas mencionadas otorgan permiso a la Asociación Latinoamericana (LAA) y sus socios para utilizar cualquier fotografía o medio capturado durante el evento con fines promocionales y de marketing. Su participación significa consentimiento, y usted renuncia a todos los derechos sobre estas imágenes.*

Agree/ De Acuerdo
By registering here, I authorize the LAA to save my information, and I agree to receive information from the organizations via email and phone. / Al registrarse aquí, autorizo a la LAA a guardar mi información, y acepto recibir información de las organizaciones por correo electrónico y teléfono.*

Yes/SiNo/ no
Should be Empty: