Nutrition Class Registration Form

Nutrition Classes

Our registered dietitian, Caitlin Provencio, provides live nutrition courses via video chat on Wednesday afternoons. Group classes are limited to 10 participants.

Classes are 30 minutes.

You will need to provide an email address for the class link to be sent. Cost is $30.

Upon submission of this form, you will be contacted by Tanque Verde Pediatrics to collect payment and confirm email address for the link. Please include your best contact information below. Thank you!
Class:
Parents's Name

First Name Last Name
Parent's Cell Phone Number
Please enter a valid phone number.
Parents's E-mail
example@example.com
Preferred method of communication (where do we send the class link?)

Cell Phone Email
Child's Name (kids do not need to be present for class)

First Name Last Name
Child's Date of Birth

Month Day Year
Date
Are there any specific topics you would like to have discussed? Please list below.
Should be Empty: