Food as Medicine Program Interest & Permission Form
This free educational program is designed to provide nutrition and exercise education to adolescents, aged 10-17 years old. Please provide your contact information and consent to enroll your adolescent in the summer program.
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Adolescent Full Name
*
First Name
Last Name
Adolescent Age
*
Is your adolescent at risk of or currently living with obesity or type-2 diabetes?
*
At risk of obesity
Currently living with obesity
At risk of type-2 diabetes
Currently living with type-2 diabetes
Other
Do you give permission for our team to contact you and enroll your adolescent in the 1-day Food as Medicine program on Wednesday, July 22?
*
Yes, I give permission
No, I do not give permission
Submit Interest
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