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Nutrition Counseling Sign Up
Welcome to nutrition counseling! Our Student Nutritionists are here to help the UMass campus community reach their health and wellness goals. Please fill out the following form to give us some more information about you! You may expect an email within 2 business days to schedule your first free session.
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Are you a Nutrition 130 student looking for extra credit? If so, follow this link: https://forms.gle/fqE2nDdGwqiTWEHi7  *
First Name *
Last Name *
Email *
Spire ID Number *
Pronouns *
Are you a member of any of the following? (check all that apply) *
Required
If you are a collegiate or club athlete, which sport do you play?
Current Status *
In one or two sentences please describe your nutritional goal(s). What are you hoping to focus on or gain while meeting with a student nutritionist? 
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Do you have any dietary restrictions such as food allergies, sensitivities, or intolerances? If yes, please describe. 
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Do you follow any special diets? 
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Do you have any health conditions or concerns which your student nutritionist should be aware of? 
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Do you follow any cultural, religious, or traditional practices that affect the way you eat? If yes, please describe. 
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Please select the times you are available to meet with a student nutritionist.  
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Monday
Tuesday
Wednesday
Thursday
Friday
8 AM - 9 AM
9 AM - 11 AM
11 AM - 1 PM
1 PM - 3 PM
3 PM - 5 PM
5 PM - 8 PM
Do you prefer to meet with a Student Nutritionist of a particular gender or with expertise in a particular area? If yes, please specify. Please note there are no guarantees.
Which type of session do you prefer? *
Is there anything else you would like to add? 
How did you hear about our program? *
If you selected referral above please type the name of the person who referred you here.
Are you interested in personal training? *
The Student Nutritionist Program relies on training and education to prepare nutrition students to work with clients. Do you give your consent for a Student Nutritionist Trainee to observe your nutrition session for training and educational purposes? 
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Release of Liability: I understand that the information and advice provided by the Student Nutritionist Program does not substitute for medical advice or attention. I voluntarily assume full responsibility for any risks associated with participation in this program. I hereby waive The Body Shop Fitness Center, UMass Department of Nutrition, UMass Department of Kinesiology, UMass Recreation and Wellbeing, Student Nutritionists, Student Nutritionist Trainees, Student Nutritionist Program Director, and associated Instructors of any liability as a result of my participation. I hereby release the Trustees of The University of Massachusetts, and the officers, employees and agents thereof, from and against all claims, legal actions, demands, judgments, expenses and costs arising out of participation in any aspect of nutrition consultation offered by The Student Nutritionist Program. In addition, I certify that I am eighteen (18) years or older. 

Please write your FULL NAME and the DATE below to signify you have read and agree to the terms above.

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