COMMUNITY SERVICES, INC. OF OCEAN COUNTY
TAKE CONTROL OF YOUR HEALTH

CHRONIC DISEASE & DIABETES SELF-MANAGEMENT WORKSHOPS

WORKSHOP REGISTRATION

WORKSHOP REGISTRATION
Is your monthly income ...?
Single: $1,073
Married: $1,452
Emergency Contact
Workshop Location
Participant Information Survey

Instructions:

Please answer the questions on both pages of this form.

Please click boxes to mark your selections with a check mark.

What is your race? (Mark all that apply) *
Has a health care provider ever told you that you have any of the following chronic conditions? (Please mark all that apply) *