CHANGE Health Community Program Registration

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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.

Each participant has to fill out this form to register, including children

Last Name *

First Name *

Birthdate *

YYYY

Gender *

Female

Male

Prefer not to say

Other:

Ethnicity

Apt #

Street # *

City *

Province *

Postal Code *

Email Address

Phone Number

Do you have a family doctor? *

Family Doctor Name:

Any dietary Restrictions? (Allergies or Intolerances, Vegetarian, Halal)

Any health or behavior concerns to be aware of?

Family members participating(full name, age, gender, ethnicity) *

Local Site for program *

Parkdale Community Hall

St. Bernadette School

McKernan School

High Park School

WoodHaven School

McDougall

Mahogany (Calgary, Alberta)

Other:

Required

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