Connecting through Traditional Foods - March 2023

Participant Information

First Name *

Last Name *

Email Address (use the email you want the Zoom links to be sent for virtual sessions): *

Phone

Address

Age: *

Birthdate (DD/MM/YYYY): *

Please select one of the following: *

Male	Female
Other/Prefer not to answer

Community Affiliation: *

I am a community member	I am a SRPMIC employee
I am a community member AND SRPMIC employee	I am neither a community member nor employee
Employee ID# Employee ID#

Points Programs: *

I am a WellPath participant	I am a StrongLife participant
I do not currently participate in a wellness points program	Other Other

How do you access the internet? Please check all that apply. *