Wellness Classes Registration
Please fill out form, this is a 3 classes nutrition series, meeting once a week for 1.45 to 2 hours for three weeks. There will be surveys to fill out and personal information will be collected but not shared with any other organizations. There will be a survey in the beginning of the series and at the end of the series of classes. You encourage you to attend all 3 classes but you are welcome to attend 1 to 3 classes.
Student Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student E-mail
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Will you be attending the Patchogue or the Amityville Classes ?
*
Patchogue
Amityville
Both
Patchogue Location Question, Will you be attending 1-2-3 classes ?
September 20
September 27
October 4
All Three Dates
Amityville Location Question, Will you be attending 1-2-3 classes?
October 30
November 6
November 13
All Three Classes
Have you attended past wellness program or event with our organization? If yes, which events did you attend?
*
Do you have any health issues? Yes or No?
Do you receive Snap Benefits?
*
Do you have barriers to accessing healthy foods and why?
*
Please provide your age range? No one under 16 can attend, Adults only classes
*
16 to 25
26 to 35
36-45
46-54
55 or older
What subjects or classes would you like for us to offer?
*
How did you hear about this program?
*
Question or Comment
Register Class
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