CHANGE Health Community Program Registration
CHANGE Health Community Program supports Alberta families to learn, or re-learn healthy living through lifelong healthy
nutrition, active lifestyles, mental well-being and positive social connections.
Parents and children will learn alongside of health professionals about nutrition, physical activity, mental wellbeing and
social connections in their community. We are inviting families in your community to participate in this research-based
program.
* Required
Each participant has to fill out this form to register, including children
Last Name
*
Your answer
First Name
*
Your answer
Birthdate
*
MM
/
DD
/
YYYY
Gender
*
Female
Male
Prefer not to say
Other:
Ethnicity
Your answer
Apt #
Your answer
Street #
*
Your answer
City
*
Your answer
Province
*
Choose
AB
BC
SK
MB
ON
QC
NB
NS
PE
YK
NL
NT
NU
Other
Postal Code
*
Your answer
Email Address
Your answer
Phone Number
Your answer
Do you have a family doctor?
*
Choose
yes
No
Family Doctor Name:
Your answer
Any dietary Restrictions? (Allergies or Intolerances, Vegetarian, Halal)
Your answer
Any health or behavior concerns to be aware of?
Your answer
Family members participating(full name, age, gender, ethnicity)
*
Your answer
Local Site for program
*
Parkdale Community Hall
St. Bernadette School
McKernan School
High Park School
WoodHaven School
Other:
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of University of Alberta.
Report Abuse
Forms
