Wellness Program Interest List - Caramel Connections Foundation

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Wellness Program Interest Listccfevents2022-12-09T16:39:03-08:00

The Caramel Connections Foundation is proud to offer a FREE wellness program to help incorporate food education, including nutrition information, recipes and cooking demonstrations to young mothers in the Inland Empire.

WE ARE CURRENTLY FORMING OUR SPRING 2023 INTEREST LIST

REGISTER TODAY!

Today's Date

We are thrilled you are interested in our wellness program! Before you fill out the rest of this form, please read our eligibility requirements to see if you qualify.

Eligibility Requirements: Willing and able to attend a weekly two-hour meeting for the 16 week program. Attendance at every meeting is requested.
Willing to have basic medical information (e.g. weight, blood pressure, height, etc.,) for you collected.

Name *

First

Last

Age

City of Residence

Phone Number *

Email *

Do you have diabetes or pre-diabetes? *

Yes
No
Decline

Do you have high cholesterol? *

Yes
No
Decline

Do you have high blood pressure? *

Yes
No
Decline

Do you prefer in-person or virtual? *

In person
Virtual
No preference

Are you pregnant or do you have children? *

Yes
No

If you have children, what are their ages? *

0-5
6-12
13-18
N/A

How did you hear about our program? *

Why do you want to join the program? *

Phone

Title

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