Thank you for your interest in scheduling an A1C Champions® program. Please click below to download the Program Request Form. If you have Adobe Acrobat, you may save the form to your computer and then complete and return it by email. Otherwise, please print the form and either scan and email, fax, or mail the completed form.

If you are unable to mail a printed form or send an electronically completed Adobe Acrobat form, please contact us at 855-A1CHAMP (855-212-4267) or info@vprpop.com. We will then send a Word version of the form for you to complete electronically and return by email. Information for returning your completed Program Request Form by email, fax or mail can be found at the bottom of the form.

The A1C Champions® Business Office will contact you within five business days to confirm receipt of your form. If you have any questions, please call 855-A1CHAMP (855-212-4267).

Adobe Reader or Acrobat is required to view and fill out the PDF, while Adobe Acrobat is required to fill out the PDF and save an electronic version of the completed form. You cannot fill out and save an electronic completed PDF unless you have Adobe Acrobat. If you are entering your information in Adobe Reader, please print the form as soon as it has been completed. To download the latest version of the free Adobe Reader, please click here.