Lifestyle & Nutrition Course Registration Form
This 13-Week Course starts Thursday, August 29th, 2024, 5:30-7:30pm. Class will be held the same time and place for thirteen weeks.

Completing this form registers you for the next Lifestyle & Nutrition Course. 
You will receive an automatic confirmation notification when your registration form is submitted. Shortly after, the host organization, UC-VEG (Umpqua Community Veg Education Group), will send an email with further details about the Course.
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Email *
First Name *
Last Name *
Date of Birth *
Zip Code *
Phone (10 digits) *
Please initial if you agree with the following: The Lifestyle & Nutrition Course is an educational program hosted by UC-VEG (Umpqua Community Veg Education Group). This class will help you better understand the connection between healthful nutrition and chronic disease prevention, along with practical basics to support a shift toward optimal health. The information presented in the classes and through the materials is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Seek the advice of your physician or other qualified health professional with any questions you may have regarding a medical condition. *
Please initial if you agree with the following: I hereby give UC-VEG the absolute right and permission, with respect to any film, photography, video or audio recordings being made of me and with respect to my participation in this class: a) To copyright, use, re-use, publish, and re-publish the same in whole or in part, in any medium; and b) To use my name in conjunction therewith, if so desired. I release and discharge UC-VEG and its contractors and agents, such as producers and filmmakers, from any and all liabilities, claims or demands arising out of or in connection with the use of these film, photographs, video or audio recordings. This authorization and release shall also run to the benefit of the volunteers, officers, directors, agents, legal representatives, licensees, and assigns of UC-VEG. I understand that I will receive no compensation, monetary or otherwise, in exchange for this agreement or for the use of these photographs, film, video or audio recordings. I have read the above and fully understand its contents. *
Is this your first time attending a CHIP, THIP, or Lifestyle & Nutrition Course? *
Will you be attending in-person or virtually? *
Would you like to attend the optional Course Orientation on Tuesday, August 27th, 5:30pm-6:30pm? This orientation is only virtual, via Zoom. This is an opportunity to address Zoom classroom details and have a conversation about goal setting for the Lifestyle & Nutrition Course. *
After submitting this form, you will be subscribed to the UC-VEG mailing list. This is how we send emails pertaining to the Course. Please add to your contact list, to prevent emails from being filtered to spam. And you are welcome to unsubscribe at any time, by selecting "unsubscribe" at the bottom of an email that comes your way.
A copy of your responses will be emailed to the address you provided.
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