In the Kitchen

In the Kitchen Registration

Nutrition Education: 2nd Wednesday, 12:00-12:30 p.m. PT & Cooking Class: 3rd Monday, 12:00-1:00 p.m. PT
Name*

First NameLast Name
Email*
example@example.com
City, State*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear about us?*
Are you a Providence employee?*

YesNo
Optional Demographic Information

Would you consider helping us continue to offer, improve, and enhance our free community classes and programs? This demographic information will help us improve our ability to serve our participants, enhance funding, and perform research around healthy lifestyle behaviors and our community-centered programming. All research data will be de-identified. We do not sell or give your information to third parties.
Would you mind answering our demographic questions?*

Happy to answer!No thanks.
Age
What race(s) do you consider yourself to be?

Alaska NativeAmerican IndianAsianBlack/African AmericanNative Hawaiian/Other Pacific IslanderWhite/CaucasianSome other racePrefer not to sayUnknown
Do you consider yourself to be Hispanic or Latino?
How do you identify?

ManNon-binaryWomanPrefer to self-describe
PARTICIPANT WAIVER

Please read the information below and then check the box indicating your understanding.
By checking the box below, you understand the following: I understand my name will be added to the Basecamp Prevention + Wellness contact list to receive information related to health and wellness. We do not share our database with outside groups.
Participant Waiver Acknowledgment*

I understand
If you have questions or comments regarding this registration or In the Kitchen, please send us an email.
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In the Kitchen Registration

PARTICIPANT WAIVER