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Health & Wellness Teleclass Registration

Please complete the following information to register for the Making Healthy Changes for Life teleclass. This information is confidential and will only be used for processing teleclass registrations.

Note: Teleclasses are for TRICARE beneficiaries only.

Class Date

Please enter the date of the class (mm-dd-yyyy) you are registering for. Ex 07-31-2016.

First Name

First name of the class participant.

Last Name

Last name of the class participant.

Last 4 digits of Sponsor Social Security Number

Please enter just the last 4 digits of the sponsor's social security number.

Date of Birth

Please enter your date of birth (mm-dd-yyyy). Ex 07-31-2016.

Gender

City

Enter your current city.

State

Time Zone

Please enter the current email address for the class participant. You must have an email address to receive reminders and updates for your teleclass.

Primary Phone Number

Please enter the 10-digit phone number for the class participant. It will be used only if we encounter problems with sending email to the address provided. Format Ex. 2011234567.

Can we leave a Voice Message?

Duty Status

Do you receive care at a military hospital or clinic?

Hospital or Clinic Name

If you do receive care at a military hospital or clinic, please enter the name of that facility here.

How did you hear about this Teleclass?

Referred by whom?

If you were referred by a Health Net Federal Services employee, please list their name or department in the above box.

Are you a Centene/Health Net Federal Services employee?