Faith Formula Assessment and Registration Form

Welcome to Debra’s Healing Kitchen

We are excited that you are interested in participating in our free online cooking classes offered by Faith Formula. In order for you to have access to the videos, we need the following information. Once you complete and submit the form, you will receive a link to access the classes. Additional classes will be added to the program each month.
Faith Formula Assessment and Registration Form

CDC REACH Grant
Name

First NameMiddle NameLast NameSuffix
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Age
Birth Date

MonthDayYear
Date
Occupation
Gender

MaleFemale
Height
Weight
Marital Status

SingleMarriedDivorcedWidow
Do you have children?

YesNo
Age(s) of children
Are you pregnant?

YesNo
Pregnancy Due Date
Do you live within 2 miles of a grocery store?
How often do you eat fast food per week?

1 time a week2 times a week3 times a weekMore than 4
Do you consume fresh fruits and vegetables on a daily basis?

YesNo
Do you suffer from any of the following chronic disease:

High Blood PressureHeart DiseaseLupusDiabetesArthritisAsthmaCancerDepressionOther
Will you agree to provide feedback after you view at least 6 of the online classes?

YesNo
We welcome your feedback and would like to know if the cooking demonstration and classes helped you make positive changes in your daily dietary habits.

If yes, please sign below:
Signature

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