Snap-Ed Resources

Address

Centre Square East, 1500 Market
Street, Philadelphia, PA 19102

Contact Information

Susan Hayes
Director, Nutrition and Active Living
suhayes@phmc.org
215.933.2838

Registration Form

Thank you for your interest in the virtual nutrition education offered by Health Promotion Council (HPC)! The following questions help HPC better understand who is taking the class. You can skip any question you do not want to answer.

Is this the first time you attended a SNAP-Ed nutrition education class provided by Health Promotion Council during this program year (since October 1, 2022)?

Yes No

Registration Form

What is your gender?

Male

Female

Prefer not to say

Please Select Gender

What is your age?

18 - 59

60 or older

Please Select Age

What is your ethnicity?

Hispanic or Latino

Not Hispanic or Latino

Please Select Ethnicity

What is your race? Check all that apply.

White

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

American Indian or Alaskan Native

Are there children under the age of 18 in your household?

Yes

Please Select children Under Age

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Registration Form

What is your zip code?

Please Enter Zip Code

What program site would you normally attend or are affiliated with?

Please Select Program Site

Who referred you to this virtual nutrition education?

The affiliated program site may
want to know the names of the individuals taking this virtual class.

Do you give HPC permission to share your name with a program site? No other identifying information such as phone number or email will be shared.

Yes, I permit HPC to share my name No, I do not permit HPC to share my name

Please Select Permission Box

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Address

Contact Information