Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Which certifications are you applying for? *

Certified Diabetes + Fitness Specialist (CDFS)®

Certified CGM Fitness Trainer (CCGMFT)®

Both

Do you currently hold any fitness or health-related certifications? *

Yes

No

What is your highest level of education? *

High School Diploma

Associate Degree

Bachelor’s Degree

Master’s Degree or Higher

Other

Do you have experience working with clients who have diabetes or other chronic conditions? *

Yes

No

Are you familiar with Continuous Glucose Monitoring (CGM) technology? *

Yes

No

Are you able to commit to completing the required coursework (CDFS: 25 hours, CCGMFT: 20 hours) within 6 months? *

Yes

No

Do you have access to a reliable internet connection for the online learning platform? *

Yes

No

How did you hear about this certification program? *

Social Media

Referral

Website/Online Search

Other

Date

MM

DD

YYYY