New Customer Registration Form

Nourish and Nurture: Nutrition Class Registration
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Birth Date *

MonthDayYear
Date
Due Date*

MonthDayYear
Date
Please choose a class:*
Will anyone be attending class with you? (Everyone is welcome to bring a support person to each class).*

YesNo
Name of the person attending & their relationship to you.
We provide childcare during our classes for children 6 and under. Will you need childcare?*

YesNo
If yes, for how many children? what are their ages? *
Please select which class you'll be attending:*
Client permission to use photographs/videos taken at BRPC. I give my full permission for BRPC to take photographs or videos of myself or my child and I understand that any written information regarding myself or my child may be used in conjunction with the BRPC marketing and advertising materials. For example, websites, Social Media, and printed material such as newsletters, but not limited to any of these. There will be no time that any affiliation of myself or my child’s name will be mentioned or tagged in any photos by BRPC.*Each picture or video posted and/or used will remain anonymous by BRPC. I give my full permission for the photos to be used by BRPC.*

YesNo
Should be Empty:

Nourish and Nurture: Nutrition Class Registration