REGISTRATION FORM

School or Organization:

Contact: Email address:	Phone:

Location:

Payment method:☐ Credit ☐ Cheque ☐ Cash	How did you hear about us?

Program Options:

☒General Nutrition and Healthy Eating Workshop (1hr) ☐Picky Eaters Workshop

* Maximum of 30 students per presentation

Proposed Dates: 1st choice 2nd choice

Time (One hour intervals)	Grade	Quantity of Students	Teacher	Severe Allergies

Additional Comments or Special Requests:

Please allow at least 1 week for cancellations. Cancellations after 1 week are subject to a $25 cancellation fee.

Jamie Gervais, B.Sc.

Email: info@foodimpact.ca

Web: http://foodimpact.ca
Cell: 587-435-7026