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If you do not have an email address please enter a phone number
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Register for the following Divabetic - Makeover Your Diabetes event
Choose Your Preferred Location New York City, NY - Wed, March 5, 2008 Philadelphia, PA - Sat, March 8, 2008 Atlanta, GA - Sat, April 12, 2008 Los Angeles CA - Sat, June 28, 2008 Washington, DC - Sat, September 27, 2008 Cleveland OH - Sat, October 11, 2008 New Orleans LA - Sat, October 25, 2008 Miami FL - Sat, November 1, 2008

GUESTS ARE WELCOME!

Number of people attending including yourself. Guests are welcome!

Please provide the first and last name, phone number, and email address of the guests you would like to bring.

***For groups of five or more, please call the Registration Phone Line (1-800-634-8888) and a DIVABETIC Team Member will contact you to complete registration for your group.

Guest #1

First Name

Last Name

Phone

Email Address

Guest #2

First Name

Last Name

Phone

Email Address

Guest #3

First Name

Last Name

Phone

Email Address

Guest #4

First Name

Last Name

Phone

Email Address

Guest #5

First Name

Last Name

Phone

Email Address

Are you familiar with Novo Nordisk?   YES    NO

Would you like to receive information about our Divabetic SPA Retreats and Cruises? YES    NO

Would you like to receive information about future Novo Nordisk and/or DIVABETIC events?  YES    NO

Would you like to join the DIVABETIC Yahoo Group? (Through your email address listed above)   YES     NO

Would you like to receive information from Novo Nordisk’s Changing Life with Diabetes educational series? YES    NO
(Through your email address listed above)

How did you learn about Divabetic-Makeover Your Diabetes? Please select all that apply.
(hold Ctrl key or Apple key on the MAC to select more than one)
Radio Newspaper Magazine Online Postcard/Flyer Church Community/Fitness Center Novo Nordisk Doctor's Office Diabetes Educator JDRF ADA CVS OTHER

If you selected other please tell us how you learned about Divabetic-Makeover:

Have you attended a previous Divabetic - Makeover Your Diabetes^TM event? YES    NO

If you checked YES, would you be interested in being contacted to share your success/experiences following the event? YES    NO

In regard to Diabetes what interests you most?
(hold Ctrl key or Applekey on the MAC to select more than one)
Type 1 diabetes Type 2 diabetes Family history of diabetes Tips on preventing diabetes ...

* Privacy Policy
By voluntarily checking the box below, I agree to the following:
I understand that the information I am providing may be used for business purposes, including providing me with additional support literature and special offers from Novo Nordisk Inc. The information that I am providing will not be shared with any third-party beyond Divabetic and Novo Nordisk.

I hereby grant to Novo Nordisk A/S, its subsidiaries, affiliates, and divisions, as well as its agents, (hereinafter known as “Novo Nordisk A/S”) the irrevocable and unrestricted right and permission to take, copyright into Novo Nordisk’s A/S name or otherwise, and use, reuse, publish and republish video, audio, or photographic portraits or pictures of me or in which I may be included, in whole or in part, or composite or distorted in character of form, without restriction as to changes or alterations, in conjunction with my own name or with no name, or reproductions thereof in color or otherwise made through any medium and in any and all media now or hereafter known for illustration, promotion, art, editorial, advertising, trade, or any other purpose whatsoever. I also consent to the use of any published matter in conjunction therewith.

I have read the above authorization, release, and agreement, prior to this execution, and I am fully familiar with the contents thereof. This release shall be binding upon me and my heirs, legal representatives and assigns.

* YES, I agree to the privacy policy.