Leah's Pantry Nutrition Class Registration
The information being requested below is only for monitoring and auditing purposes, as required by grant funding, and is not intended for public dissemination. All information is confidential.
Which class are you registering for? *
Email Address *
Last Name *
First Name *
Phone Number *
Street Address *
City *
State *
Zip Code *
Emergency Contact Name *
Emergency Contact Phone Number *
Emergency Contact Relationship *
Age Range *
What is your gender? *
Please Check all that Apply *
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Race *
If you have ONE person in your household please answer select your total household income *
If you have TWO people in your household please answer select your total household income *
(REQUIRED) CONSENT TO PARTICIPATE IN Leah's Pantry Food Smarts Program: I hereby certify that the above information is true and correct, participation at the class, in-home, or online via YouTube or any other live class is at my own risk. I understand the Healthy Aging Association, their agents, officers, employees, and volunteers are hosting the class without compensation and participation in the online class is of my own accord. I also grant full permission to Healthy Aging Association to use my photograph in any publication or advertising materials. I agree that the Healthy Aging Association, their employees, and agents, shall not be responsible in any way for the content of news media coverage in which the photography authorized herein is used. Please PRINT your full name. *
Please enter today's date, in which you agree to the above terms. *
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